Speech and Language Therapy For Aphasia Following Stroke 2010

Title
Speech and language therapy for aphasia following stroke
Author(s)
Kelly, Helen; Brady, Marian C.; Enderby, Pam
Publication date
2010
Original citation
Kelly H, Brady MC, Enderby P. Speech and language therapy for

aphasia following stroke. Cochrane Database of Systematic Reviews
2010, Issue 5. Art. No.: CD000425. DOI:
10.1002/14651858.CD000425.pub2.
Type of publication
Article (peer-reviewed)
Link to publisher's
version
http://dx.doi.org/10.1002/14651858.CD000425.pub3
http://dx.doi.org/10.1002/14651858.CD000425.pub2
Access to the full text of the published version may require a
subscription.
Rights
Copyright 2010 The Cochrane Collaboration.
Item downloaded
from
http://hdl.handle.net/10468/1418
Downloaded on 2016-07-17T07:51:08Z

(Review)
Kelly H, Brady MC, Enderby P
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2010, Issue 7
http://www.thecochranelibrary.com
Speech and language therapy for aphasia following stroke (Review)

Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 SLT versus no SLT, Outcome 1 Functional communication. . . . . . . . . . .
Analysis 1.2. Comparison 1 SLT versus no SLT, Outcome 2 Receptive language: auditory comprehension. . . . .
Analysis 1.3. Comparison 1 SLT versus no SLT, Outcome 3 Receptive language: reading comprehension. . . . .
Analysis 1.4. Comparison 1 SLT versus no SLT, Outcome 4 Receptive language: other. . . . . . . . . . . .
Analysis 1.5. Comparison 1 SLT versus no SLT, Outcome 5 Receptive language: gesture comprehension (unnamed).
Analysis 1.6. Comparison 1 SLT versus no SLT, Outcome 6 Expressive language: naming. . . . . . . . . . .
Analysis 1.7. Comparison 1 SLT versus no SLT, Outcome 7 Expressive language: general. . . . . . . . . . .
Analysis 1.8. Comparison 1 SLT versus no SLT, Outcome 8 Expressive language: written. . . . . . . . . . .
Analysis 1.9. Comparison 1 SLT versus no SLT, Outcome 9 Expressive language: repetition. . . . . . . . . .
Analysis 1.10. Comparison 1 SLT versus no SLT, Outcome 10 Severity of impairment: Aphasia Battery Score (+ PICA).
Analysis 1.11. Comparison 1 SLT versus no SLT, Outcome 11 Severity of impairment: Aphasia Battery Score (3-month
follow up). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.12. Comparison 1 SLT versus no SLT, Outcome 12 Psychosocial: MAACL. . . . . . . . . . . .
Analysis 1.13. Comparison 1 SLT versus no SLT, Outcome 13 Number of drop-outs (any reason). . . . . . . .
Analysis 2.1. Comparison 2 SLT versus social support and stimulation, Outcome 1 Functional communication. . .
Analysis 2.2. Comparison 2 SLT versus social support and stimulation, Outcome 2 Receptive language: auditory
comprehension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.3. Comparison 2 SLT versus social support and stimulation, Outcome 3 Receptive language: other. . . .
Analysis 2.4. Comparison 2 SLT versus social support and stimulation, Outcome 4 Expressive language: single words.
Analysis 2.5. Comparison 2 SLT versus social support and stimulation, Outcome 5 Expressive language: sentences. .
Analysis 2.6. Comparison 2 SLT versus social support and stimulation, Outcome 6 Expressive language: picture
description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.7. Comparison 2 SLT versus social support and stimulation, Outcome 7 Expressive language: overall spoken.
Analysis 2.8. Comparison 2 SLT versus social support and stimulation, Outcome 8 Expressive language: written. . .
Analysis 2.9. Comparison 2 SLT versus social support and stimulation, Outcome 9 Severity of impairment: Aphasia Battery
Score. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.10. Comparison 2 SLT versus social support and stimulation, Outcome 10 Number of drop-outs for any
reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.1. Comparison 3 Functional SLT (SLTA) versus conventional SLT (SLTB), Outcome 1 Functional
communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
communication: catalogue ordering. . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.3. Comparison 3 Functional SLT (SLTA) versus conventional SLT (SLTB), Outcome 3 Expressive language:
spoken. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.4. Comparison 3 Functional SLT (SLTA) versus conventional SLT (SLTB), Outcome 4 Expressive language:
written. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.1. Comparison 4 Intensive SLT (SLTA) versus conventional SLT (SLTB), Outcome 1 Receptive language:
auditory comprehension (change from baseline). . . . . . . . . . . . . . . . . . . . . . .
1
1
2
2
4
4
7
28
31
32
32
38
89
97
98
99
100
100
101
102
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104
105
106
106
107
108
109
110
110
111
112
113
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118
i
Analysis 4.2. Comparison 4 Intensive SLT (SLTA) versus conventional SLT (SLTB), Outcome 2 Expressive language:
spoken (change from baseline scores).
. . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.3. Comparison 4 Intensive SLT (SLTA) versus conventional SLT (SLTB), Outcome 3 Written language: (change
from baseline scores). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.4. Comparison 4 Intensive SLT (SLTA) versus conventional SLT (SLTB), Outcome 4 Severity of impairment:
Aphasia Battery Score. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.5. Comparison 4 Intensive SLT (SLTA) versus conventional SLT (SLTB), Outcome 5 Number of drop-outs for
any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.1. Comparison 5 Volunteer-facilitated SLT (SLTA) versus professional SLT (SLTB), Outcome 1 Functional
communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.2. Comparison 5 Volunteer-facilitated SLT (SLTA) versus professional SLT (SLTB), Outcome 2 Receptive
language: auditory comprehension. . . . . . . . . . . . . . . . . . . . . . . . . . .
language: reading comprehension. . . . . . . . . . . . . . . . . . . . . . . . . . . .
language: other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.5. Comparison 5 Volunteer-facilitated SLT (SLTA) versus professional SLT (SLTB), Outcome 5 Expressive
language: spoken. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
language: repetition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
language: written. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.8. Comparison 5 Volunteer-facilitated SLT (SLTA) versus professional SLT (SLTB), Outcome 8 Severity of
impairment: Aphasia Battery Score. . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.9. Comparison 5 Volunteer-facilitated SLT (SLTA) versus professional SLT (SLTB), Outcome 9 Number of
drop-outs for any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 6.1. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 1 Receptive language: auditory
comprehension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 6.2. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 2 Receptive language: other. .
Analysis 6.3. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 3 Expressive language: spoken.
Analysis 6.4. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 4 Expressive language: repetition.
Analysis 6.5. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 5 Expressive language: written.
Analysis 6.6. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 6 Severity of impairment: Aphasia
Battery Score. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 6.7. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 7 Severity of impairment: Aphasia
Battery Score (3-month follow up). . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 6.8. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 8 Number of drop-outs for any
reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.1. Comparison 7 Task-specific SLT (SLTA) versus conventional SLT (SLTB), Outcome 1 Functional
communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.2. Comparison 7 Task-specific SLT (SLTA) versus conventional SLT (SLTB), Outcome 2 Receptive language:
auditory comprehension - word. . . . . . . . . . . . . . . . . . . . . . . . . . . .
other auditory comprehension. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
auditory comprehension (treated items). . . . . . . . . . . . . . . . . . . . . . . . . .
reading comprehension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
other.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.7. Comparison 7 Task-specific SLT (SLTA) versus conventional SLT (SLTB), Outcome 7 Expressive language:
spoken naming. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
119
119
120
121
121
122
123
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124
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126
127
128
128
129
130
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ii
spoken sentence construction. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
other spoken tasks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
spoken (treated items). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
repetition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
written. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.13. Comparison 7 Task-specific SLT (SLTA) versus conventional SLT (SLTB), Outcome 13 Severity of
impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.14. Comparison 7 Task-specific SLT (SLTA) versus conventional SLT (SLTB), Outcome 14 Number of dropouts for any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.1. Comparison 8 Operant training SLT (SLTA) versus conventional SLT (SLTB), Outcome 1 Receptive language:
auditory comprehension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.2. Comparison 8 Operant training SLT (SLTA) versus conventional SLT (SLTB), Outcome 2 Receptive language:
other.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.3. Comparison 8 Operant training SLT (SLTA) versus conventional SLT (SLTB), Outcome 3 Expressive
language: spoken. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.4. Comparison 8 Operant training SLT (SLTA) versus conventional SLT (SLTB), Outcome 4 Expressive
language: written. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.5. Comparison 8 Operant training SLT (SLTA) versus conventional SLT (SLTB), Outcome 5 Severity of
impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.1. Comparison 9 Semantic SLT (SLTA) versus phonological SLT (SLT B), Outcome 1 Functional
communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.2. Comparison 9 Semantic SLT (SLTA) versus phonological SLT (SLT B), Outcome 2 Receptive language:
auditory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.3. Comparison 9 Semantic SLT (SLTA) versus phonological SLT (SLT B), Outcome 3 Receptive language:
reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.4. Comparison 9 Semantic SLT (SLTA) versus phonological SLT (SLT B), Outcome 4 Expressive language:
repetition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.5. Comparison 9 Semantic SLT (SLTA) versus phonological SLT (SLT B), Outcome 5 Number of drop-outs for
any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 10.1. Comparison 10 Filmed programmed instruction SLT (SLT A) versus non-programmed activity SLT (SLTB),
Outcome 1 Receptive language: auditory. . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 10.2. Comparison 10 Filmed programmed instruction SLT (SLT A) versus non-programmed activity SLT (SLTB),
Outcome 2 Receptive language: reading. . . . . . . . . . . . . . . . . . . . . . . . .
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

139
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iii
[Intervention Review]

Helen Kelly2, Marian C Brady1 , Pam Enderby3
1 Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK. 2 (a) Nursing,
Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK, (b) Speech and Hearing Sciences, Queen
Margaret University, Edinburgh, UK. 3 School of Health and Related Research, University of Sheffield, Sheffield, UK
Contact address: Marian C Brady, Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University,
Cowcaddens Road, Glasgow, G4 0BA, UK. m.brady@gcal.ac.uk.
Editorial group: Cochrane Stroke Group.
Publication status and date: Edited (no change to conclusions), published in Issue 7, 2010.
Review content assessed as up-to-date: 8 November 2009.
Citation: Kelly H, Brady MC, Enderby P. Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic
Reviews 2010, Issue 5. Art. No.: CD000425. DOI: 10.1002/14651858.CD000425.pub2.
ABSTRACT
Background
Aphasia is an acquired language impairment following brain damage which affects some or all language modalities: expression and
understanding of speech, reading and writing. Approximately one-third of people who have a stroke experience aphasia.
Objectives
To assess the effectiveness of speech and language therapy (SLT) for aphasia following stroke.
Search strategy
We searched the Cochrane Stroke Group Trials Register (last searched April 2009), MEDLINE (1966 to April 2009) and CINAHL
(1982 to April 2009). In an effort to identify further published, unpublished and ongoing trials we handsearched the International
Journal of Language and Communication Disorders, searched reference lists of relevant articles and contacted other researchers and
authors.
Selection criteria
Randomised controlled trials comparing SLT versus no SLT, SLT versus social support or stimulation, and one SLT intervention
versus another SLT intervention. SLT refers to a formal speech and language therapy intervention that aims to improve language and
communication abilities and in turn levels of communicative activity and participation. Social support and stimulation refers to an
intervention which provides social support or communication stimulation but does not include targeted therapeutic interventions.
Direct comparisons of different SLT interventions refers to SLT interventions that differ in terms of duration, intensity, frequency or
method of intervention or in the theoretical basis for the SLT approach.
Data collection and analysis
Two review authors independently extracted the data and assessed the quality of included trials. We sought missing data from study
investigators if necessary.
Main results
We included 30 trials (41 paired comparisons) in the review: 14 subcomparisons (1064 participants) compared SLT with no SLT;
six subcomparisons (279 participants) compared SLT with social support and stimulation; and 21 subcomparisons (732 participants)
compared two approaches to SLT. In general, the trials randomised small numbers of participants across a range of characteristics (age,
time since stroke and severity profiles), interventions and outcomes. Suitable statistical data were unavailable for several measures.
Authors conclusions
This review shows some indication of the effectiveness of SLT for people with aphasia following stroke. We also observed a consistency in
the direction of results which favoured intensive SLT over conventional SLT, though significantly more people withdrew from intensive
SLT than conventional SLT. SLT facilitated by a therapist-trained and supervised volunteer appears to be as effective as the provision
of SLT by a professional. There was insufficient evidence to draw any conclusions in relation to the effectiveness of one SLT approach
over another.
PLAIN LANGUAGE SUMMARY

Language problems following a stroke are called aphasia (or dysphasia). About one-third of all people who experience stroke develop
aphasia, which can affect one or more areas of communication (speaking, understanding spoken words, reading and writing). Speech
and language therapists are involved in the assessment, diagnosis and treatment of aphasia at all stages of recovery, and work closely with
the person with aphasia and their carers. There is no universally accepted treatment that can be applied to every person with aphasia.
We identified 30 trials involving 1840 randomised participants that were suitable for inclusion in this review. Overall, the review shows
evidence from randomised trials to suggest there may be a benefit from speech and language therapy but there was insufficient evidence
to indicate the best approach to delivering speech and language therapy.
BACKGROUND
The term aphasia (less commonly referred to as dysphasia) is used
to describe an acquired loss or impairment of the language system following brain damage (Benson 1996) and excludes other
communication difficulties attributed to sensory loss, confusion,
dementia or speech difficulties due to muscular weakness or dysfunction such as dysarthria. The most common cause of aphasia is
a cerebrovascular accident (commonly known as stroke), mainly
to the left hemisphere, where the language function of the brain
is usually situated for right-handed people. About one-third of all
people who experience a stroke develop aphasia (Engelter 2006;
Laska 2001). The aphasic population is heterogeneous, with individual profiles of language impairment varying in terms of severity
and degree of involvement across the modalities of language processing, including the expression and comprehension of speech,
reading, writing and gesture (Code 2003; Parr 1997). Variation in
severity of expressive impairments, for example, may range from
the individual experiencing occasional word-finding difficulties
to having no effective means of communication. The severity of
aphasia can also change over time as one area of language difficulty
may improve while others remain impaired. The impact and the
consequential implications of having aphasia for the individuals
themselves, their families and society highlight the importance of
the effective management and rehabilitation of language difficulties caused by aphasia.
The primary aim of speech and language therapy (SLT*) in aphasia
management and rehabilitation is to maximise individuals ability to communicate. Speech and language therapists are typically
responsible for the assessment, diagnosis and, where appropriate,
rehabilitation of aphasia arising as a result of stroke. The ability to
successfully communicate a message via spoken, written or nonverbal modalities (or a combination of these) within day-to-day
interactions is known as functional communication. Recent developments have seen speech and language therapists working closely
with the person with aphasia, and in partnership with their families and carers to maximise the individuals functional communication. There is no universally accepted treatment that can be
applied to every patient with aphasia and therapists select from a
variety of methods to manage and facilitate rehabilitation includ-

ing, for example, impairment-based therapy and social participation approaches. We undertook this review update to incorporate
new evidence, new systematic review methodologies and to reflect
recent developments in clinical practice. Details of the differences
between this version and the original review published in 1999 are
detailed below.
* For the purposes of clarity within this review we have reserved
the abbreviation of SLT for speech and language therapy alone.
Amendments to the original review

Following close inspection of the original review and detailed discussion amongst this review team, we made adjustments to the
review, many of which reflect changes in Cochrane procedures,
review methodologies, and style and structure in the time since the
publication of the original review. These amendments were ratified
by the Cochrane Stroke Group Editorial Board on 23 November
2006.
Types of outcome measures

We have refined the Types of outcome measures to a single primary outcome measure of functional communication. Secondary
outcomes include other measures of communication (receptive or
expressive language, or both), psychosocial outcomes, patient satisfaction with the intervention, number of participant drop-outs
for any reason, non-compliance with the allocated intervention,
economic outcomes (such as cost to the patient, carers, families,
health service and society) and carer or family satisfaction. Data
relating to death, morbidity and cognitive skills were extracted in
the original review but, on reflection, we did not consider these to
be relevant indicators of the effectiveness of a speech and language
therapy intervention and we therefore excluded them from this
update. The original review had measures of overall functional status (e.g. Barthel Index) as one of a number of primary outcomes.
As described above, we focused on a single primary outcome (in
line with the current review methodology).
Data extraction tool

Background
We have updated the Background section to include a definition
of speech and language therapy and aphasia, and to reflect current
approaches and rationale to speech and language therapy interventions and outcomes.
We could not obtain the original data extraction tool, therefore

two of the review authors (HK and MB) created and piloted a new
one before use.
Search methods for identification of studies

Objectives
We amended the Objectives to a single statement according to the
standard format of Cochrane reviews; that is, to examine the effectiveness of speech and language therapy interventions for aphasia
following stroke.
Types of studies
It was unclear whether or not quasi-randomised controlled trials
were included in the original review. We have excluded quasirandomised trials in this update.
Re-running the original search strategy for the MEDLINE and

CINAHL databases raised over 12.6 million references. Therefore, Brenda Thomas, the Cochrane Stroke Group Trials Search
Co-ordinator, devised up-to-date search strategies. The International Journal of Language and Communication Disorders (previously named the British Journal of Disorders of Communication, the
European Journal of Disorders of Communication and the International Journal of Disorders of Communication) was handsearched
from 1969 to 2005. This journal has been indexed by MEDLINE
since 2006 and was thus included in our electronic searches from
this date.
Description of studies
Types of interventions
We have compressed the Types of interventions into three broad
categories: SLT versus no SLT intervention, SLT versus social support or stimulation, and SLT intervention A versus SLT intervention B (where A and B refer to two different types of therapeutic
interventions or approaches).
The original review listed studies other than identified randomised

controlled trials in the Characteristics of excluded studies table, including single case or case series studies. As there are a vast number
of such studies, the updated table now only presents potentially
relevant studies that appear to be randomised but which were excluded for other reasons (for example quasi-randomised or where
aphasia-specific data could not be extracted).

Comparisons
Mid-trial outcome scores were included in the original review. We
have focused our reporting on post-intervention and follow-up
scores. We have not included analysis of the number of participants
who deteriorated on particular outcome measures.
Other amendments
As we were unable to obtain the extraction sheets for the trials included in the original review, we cross-checked the data extracted
for the original review with the available published and unpublished data. We made some amendments, including exclusion of
some studies and categorising the methods of allocation concealment used in the included trials.
In this review update we took the decision to exclude quasi-randomised studies and so one study, included in the original review,
has been excluded from this review update (Hartman 1987).
On review of the data from another trial (Kinsey 1986), we decided
that the reported comparison was not a therapy intervention as
such, but rather a comparison of task performance (computerbased or with a therapist). We thus excluded this trial from the
review update.
The allocation concealment for one study (MacKay 1988) was
considered inadequate in the original review. We failed to get
confirmation of the method of allocation from the authors and
therefore we amended the allocation for this trial to unclear.
The original review included a matched control group of no SLT
intervention for one trial (Prins 1989). However, unlike the other
groups in this trial, this group was not randomised, therefore we
have excluded it from this update.
Another study (Shewan 1984) had been excluded from the original
review on the grounds that it was not a randomised controlled
trial. Discussion with the trialists has since revealed that it was a
randomised controlled trial, and we have now included it in the
review.
The original review included outcomes relating to the impact of
SLT on the emotional wellbeing of family members (Lincoln
1984a). We do not feel that such outcomes directly relate to the
aims of this review and so we have not included these measures.
1. SLT is more effective than no SLT;

2. SLT is more effective than social support and stimulation;
3. One SLT intervention (SLTA) is more effective than
another SLT intervention (SLTB).
SLT intervention A or B refers to variations in intervention that
differ in duration, intensity, frequency, method or in the theoretical
basis of the approach to the intervention (for example, cognitive
neurological versus psychosocial based interventions).
METHODS
Criteria for considering studies for this review
Types of studies
Randomised controlled trials that evaluated (one or more) interventions designed to improve language or communication. We
included trials that recruited participants with mixed aetiologies
or impairments provided it was possible to extract the data specific
to individuals with post-stroke aphasia. We did not employ any
language restriction.
Types of participants
Adults who had acquired aphasia as a result of a stroke.
Types of interventions
The groupings presented in the original review were compressed
into three broad groups for this review update. We have included
trials which reported a comparison between a group that received
a SLT intervention designed to have an impact on communication
and a group that received:
no SLT intervention; or
social support and stimulation; or
an alternative SLT intervention.
New information added to the review

Following an extensive search up to April 2009, we identified an
additional 20 trials as suitable for inclusion in the review. There are
now 30 included trials involving 1840 randomised participants.
OBJECTIVES
To examine the effectiveness of SLT for aphasia after stroke and
in particular if:
Speech and language therapy (SLT)
We considered SLT interventions to be any form of targeted practice tasks or methodologies with the aim of improving language or
communication abilities. These are typically delivered by speech
and language therapists. In the UK, Speech and language therapist is a protected professional title and refers to individuals holding a professional qualification recognised by the Royal College of
Speech and Language Therapists and registered with the Health
Professions Council, UK. For the purposes of this review we have

extended this definition to include therapists belonging to a body

of similar professional standing elsewhere in the world.
We are aware that the speech and language therapy profession
does not exist in many countries and so in trials conducted in
such settings where other clinical staff (for example, medical or
nursing staff ) led targeted interventions that aimed to improve
participants communicative functioning we have included these
interventions within this review as speech and language therapy
interventions.
We also recognise that current rehabilitation practice may include
SLT interventions that aim to improve communicative functioning but are delivered by non-therapists (family members, SLT assistants, SLT students, voluntary support groups). Where those
delivering the intervention have received training from a speech
and language therapist and deliver an intervention designed by a
speech and language therapist, we have described these as volunteer-facilitated SLT interventions.
Social support and stimulation
Daily Living (CADL) (Holland 1980) or the Communicative Effectiveness Index (CETI) (Lomas 1989).
Secondary outcomes
Given the lack of a comprehensive, reliable, valid and globally accepted functional communication evaluation tool, surrogate outcome measures of communication ability include formal measures
of receptive language (oral, written and gestural), expressive language (oral, written and gestural) or overall level of severity of
aphasia where receptive and expressive language are measured using language batteries. Such tools might include, for example, the
Western Aphasia Battery (WAB) (Kertesz 1982) or the Porch Index of Communicative Abilities (PICA) (Porch 1967). Other secondary outcomes of relevance to this review include psychosocial
impact (i.e. impact on psychological or social wellbeing including depression, anxiety and distress); patient satisfaction with intervention; number of drop-outs (i.e. the number of participants
dropping out at treatment or follow-up phases for any reason);
compliance with allocated intervention (i.e. the number of participants voluntarily withdrawing from their allocated intervention);
economic outcomes (such as costs to the patient, carers, families,
health service and society), and carer and family satisfaction. Measures of overall functional status (e.g. Barthel) were extracted in
the original review as one of a number of primary outcomes. We
also extracted these data, where available, but this information is
now presented as a patient descriptor within the Characteristics of
included studies table. A full list of outcome measures included in
the review and their references can be found in Appendix 4.
Social support and stimulation refers to an intervention that provides social support or stimulation but does not include targeted
therapeutic interventions that aim to resolve participants expressive or receptive speech and language impairments. Interventions
in this category might include, for example, emotional, psychological or creative interventions (such as art, dance or music) as delivered by other healthcare professionals (for example, art, physical
or music therapists). Other social stimulation interventions, such
as conversation or other informal, unstructured communicative
interactions are also included in this category.
We did not include pharmacological interventions for aphasia in
this review as they are addressed elsewhere (Greener 2001).
Search methods for identification of studies
Types of outcome measures
See the Specialized register section in the Cochrane Stroke Group

module.
Primary outcomes
Electronic searches
The primary outcome to indicate the effectiveness of an intervention that aims to improve communicative ability must be the
ability to communicate in real world settings, i.e. functional communication. Providing a definition for the concept of functional
communication is problematic and even more difficult to evaluate. The ability to functionally communicate relates to language
or communicational skills sufficient to permit the transmission of
a message via spoken, written or non-verbal modalities, or a combination of these channels. Success is typically and naturalistically
demonstrated through successful communication of the message
- the speaker communicates their message and the listener understands the message communicated. Attempts to measure this
communication success formally vary from analysis of discourse
interaction in real life to sampling of specific discourse tasks. Other
more formal tools might include the Communicative Abilities of
We searched the Cochrane Stroke Group Trials Register, which was

last searched by the Managing Editor on 7 April 2009. In addition,
we searched MEDLINE (January 1999 to April 2009) (Appendix
1) and CINAHL (January 1999 to April 2009) (Appendix 2)
using comprehensive search strategies. For the previous version of
the review searches of MEDLINE (1966 to 1998) and CINAHL
(1982 to 1998) were carried out using simple combinations of text
words describing aphasia and speech and language therapy.
Searching other resources
1. We handsearched the International Journal of Language and
Communication Disorders (formerly the International Journal of
Disorders of Communication, the European Journal of Disorders of
Communication and the British Journal of Disorders of

Communication) from 1969 to December 2005. Since 2006 this

journal has been indexed in MEDLINE so our comprehensive
electronic search identified any relevant trials published in the
journal after that date.
2. We checked reference lists of all relevant articles to identify
other potentially relevant randomised studies.
3. We contacted all British universities and colleges where
SLTs are trained and all relevant Special Interest Groups in the
UK to enquire about any relevant published, unpublished or
ongoing studies.
4. We approached colleagues and authors of relevant
randomised trials to identify additional studies of relevance to
this review.
We did not impose any language restrictions.
Data collection and analysis
Selection of studies
Our selection criteria for inclusion in this review were:
1. the study participants included people with aphasia as a
result of stroke;
2. the SLT intervention was designed to have an impact on
communication; and
3. the methodological design was a randomised controlled
trial.
One review author (HK) screened references identified through
the search strategy described above and obtained hard copies
of all trials that fulfilled the listed inclusion criteria. In the
Characteristics of excluded studies table, we have listed studies
judged ineligible for inclusion together with reasons for their exclusion. Two review authors (HK and MB) independently made
the decision whether to include or exclude studies and they resolved any disagreements through discussion.
Data extraction and management

The data extraction form used in the original review was unavailable so we created and piloted another for use in this review update.
Two review authors (HK and MB) independently confirmed the
data for the trials as included in the original review and extracted
the data for the additional trials included in the update. Any disagreements were resolved through discussion and we extracted the
following data: number of sites; methods of randomisation; blinding; attrition from intervention; co-interventions; confounder details; number of participants; age; education; handedness; gender;
native language; severity of aphasia; time post-onset; frequency
and duration of therapy; details of intervention; outcome measures used and time points; evidence of an a priori sample size
calculation; intention-to-treat analysis; and summary data. We at-
tempted to contact investigators for any missing data (or data in

a suitable format) for inclusion in the review.
If we identified a cross-over trial design, we considered the suitability of the trial for inclusion in the review in view of a range
of factors including the intervention(s) used, the timing of the intervention(s), the impact of any treatment carry over and whether
data from relevant paired comparisons within the trial were available. Whenever possible, in such cases we sought individual patient data from the trialists.
Assessment of risk of bias in included studies

We assessed the trials for methodological quality, paying attention to whether there was protection from the following types of
bias: selection bias (i.e. true random sequencing and true concealment up to the time of allocation), performance bias (i.e. differences in other types of treatment (co-interventions) between the
groups), attrition bias (i.e. withdrawal after trial entry), and detection bias (i.e. unmasked assessment of outcome). We coded concealed allocation as adequate, unclear, or inadequate according
to the Cochrane Handbook for Systematic Reviews of Interventions
(Higgins 2008). In addition, we extracted information on whether
power calculations and intention-to-treat analyses were employed.
In some cases, for example where all participants were accounted
for in the final results, this was not applicable.
Measures of treatment effect

We conducted the review using Review Manager (RevMan 2008)
for statistical analysis. We have recorded descriptive information
for each trial (characteristics of participants, interventions and
outcomes) in the Characteristics of included studies table and issues relating to the methodological quality of the trial in the Risk
of bias tables. Where trials made a similar comparison and were
judged sufficiently similar in respect of their descriptive information, we pooled the summary data (where available) using metaanalysis. We expressed continuous data as differences in means or
standardised difference in means and dichotomised data as odds
ratio (OR). We used 95% confidence intervals (CI) throughout
the review.
The results of the trials in this review reported measures based on
differences in final value scores (scores taken at the end of the intervention) and change-from-baseline scores (also known as change
scores). Although the mean differences based on change-frombaseline scores in randomised trials can generally be assumed to
address the same intervention effects as mean difference analysis
based on final value scores, change-from-baseline scores are given
higher weights in analysis than final value scores (Higgins 2008).
For this reason, we have used final value scores within the metaanalyses wherever possible. We will not report change-from-baseline scores unless they are the only available values used to report
trial results (Higgins 2008).

Assessment of heterogeneity
We assessed heterogeneity using the I statistic with a value of
greater than 50% indicating substantial heterogeneity. Where
we observed substantial heterogeneity we used a random-effects
model.
Data synthesis
Where a single outcome measure was assessed and reported across
trials using different measurement tools, we presented these data
in a meta-analysis using a standardised mean differences summary
statistic. In cases where the direction of measurement differed it
was necessary to adjust the direction of some measures to ensure
that all the scales operated in the same direction. For example,
measures of comprehension ability generally increase with increasing ability, but in some cases (e.g. the Token Test) improving comprehension skills might be reflected by decreasing scores and so it
was necessary to multiply the mean values by -1 to ensure that all
the scales operated in the same direction. Standard deviation values were unaffected and we have presented these within the metaanalysis without the need for a directional change.
In cases where only partial summary data were reported, for example mean final value scores were available but standard deviations
were unavailable (Wertz 1981), we attempted to calculate these
values from available information. When this was not possible we
imputed the standard deviation to facilitate inclusion of the trial
within the review by using a standard deviation value from a similar participant group (Higgins 2008). We have reported details
of where the imputed standard deviation values have come from
within the text. Where there was a choice of possible standard
deviation values, we took the approach of imputing the highest
and lowest values to ensure that both methods provided a similar
overall conclusion and then used the highest value in the presentation of the trial within the forest plot.
Where results in a particular comparison were only available in a
mixture of final value and change from baseline scores, we presented these data graphically using standardised mean differences
but we were unable to pool these results in a meta-analysis.
Subgroup analysis and investigation of heterogeneity

We did not plan any subgroup analyses.
Sensitivity analysis
The original review did not include any planned sensitivity analyses. However, in this updated review we aimed to reflect developments in clinical practice including trials where SLT interventions
were delivered or facilitated by non-speech and language therapists. We planned to conduct sensitivity analyses to evaluate any
impact the inclusion of these groups of trials may have had on the
results of the review.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of
excluded studies; Characteristics of studies awaiting classification;
Characteristics of ongoing studies.
The original review included 12 trials. We revisited the decision
taken in the original review to include Kinsey 1986 and Hartman
1987. Quasi-randomised trials such as Hartman 1987 have been
excluded from this review update while Kinsey 1986 reports a
comparison of methods of providing therapy materials rather than
a comparison of therapy interventions. Thus of the original 12
trials included in the review, 10 trials remain in this review update. In addition, we revised the decision to exclude one other
trial (Shewan 1984) from the original review following communication with the trialists who confirmed that it was a randomised
controlled trial.
Results of the search
In our substantially updated search we identified an additional
42 studies of potential relevance to the review (January 1999 to
April 2009). Eight of the 42 newly identified trials required translation; six Chinese (Gu 2003; Jufeng 2005; Liu 2006, Wang 2004;
Wu 2004; Zhang 2004), one Dutch (van Steenbrugge 1981) and
one German paper (Jungblut 2004) for which the translation was
provided by the author. Nine studies are ongoing (ACTNow;
IHCOP; Kukkonen 2007; Laska 2008; Maher 2008; RATS2;
SEATAS; SP-I-RiT; Varley 2005); these may be eligible for inclusion in the review at a later date. These studies are detailed in
the Characteristics of ongoing studies table. One study is awaiting translation (Liu 2006). In total we identified 20 new trials as
eligible for inclusion in this review update.
Included studies
We have included a total of 30 trials in this review (10 from
the original review and 20 identified for this update), which randomised a total of 1840 participants. Six trials randomised individuals across three or more groups (trial arms) but for the purposes
of meta-analyses we have presented and pooled the data within
paired comparisons. Thus in this review, we have presented the
data from these five trials in paired subcomparisons. For example, data from Jufeng 2005 were divided into three subcomparisons of (1) group SLT versus no SLT (Jufeng 2005i), (2) individual SLT versus no SLT (Jufeng 2005ii) and (3) group SLT versus individual SLT (Jufeng 2005iii). Other subcomparisons were
Katz 1997i; Katz 1997ii; Lincoln 1982i, Lincoln 1982ii, Lincoln
1982iii, Shewan 1984i; Shewan 1984ii; Shewan 1984iii; Smith
1981i; Smith 1981ii; Smith 1981iii; Wertz 1986i; Wertz 1986ii;
Wertz 1986iii. Further details can be found in the Characteristics

of included studies. As we used paired subcomparisons within this

review, there was a risk of including the same group of participants
(usually the control group) twice in a single meta-analysis. In such
cases we split the number of participants in the control group
across the two subcomparisons (Higgins 2008). In the case of continuous data the mean and standard deviation values remained the
same. In the case of dichotomous data both the number of events
and total number of patients would be split across the relevant
number of arms.
Four trials (eight subcomparisons) employed a cross-over design
(Elman 1999; Lincoln 1982i; Lincoln 1982ii; Lincoln 1982iii;
Lincoln 1984b; Wertz 1986i; Wertz 1986ii; Wertz 1986iii). We
carefully considered the suitability of each cross-over trial for inclusion within the review. We considered factors including the
suitability of the design, the intervention(s) used, the timing of
the intervention(s), the impact of any treatment carry over and
finally whether data from relevant paired comparisons from the
cross-over data were available. For five subcomparisons we only
extracted data up to the point of cross-over (Elman 1999; Lincoln
1982iii; Lincoln 1984b; Wertz 1986i; Wertz 1986ii). In some cases
though, the treatment that participants were allocated to receive
following cross-over was no SLT. In these cases, the no SLT
input after cross-over could be used as a follow-up period. In some
cases (e.g. Wertz 1986iii) it was also possible to make suitable
paired comparisons within the trial arms during this phase.
In contrast, Lincoln 1982 was also cross-over in design with participants randomly allocated to one of four groups with a sequence of
1. SLT versus no SLT
We included 14 subcomparisons in this section (Doesborgh

2004b; Jufeng 2005i; Jufeng 2005ii; Katz 1997i; Katz 1997ii;
Lincoln 1984a; Lyon 1997; MacKay 1988; Smania 2006; Smith
1981i; Smith 1981ii; Wertz 1986i; Wertz 1986ii; Wu 2004) involving 1064 randomised participants. The SLT intervention was
facilitated by a therapist-trained volunteer in two subcomparisons
(MacKay 1988; Wertz 1986ii) and by a doctor or nurse in three
subcomparisons conducted in China, where the speech and language therapy profession does not exist (Jufeng 2005i; Jufeng
2005ii; Wu 2004). Two additional trials (Prins 1989; Shewan
1984) also compared groups that did and did not receive SLT
but the participants were not randomly assigned to these no SLT
groups and were thus excluded from this review.
The subcomparisons in this section employed a range of SLT
interventions, namely conventional SLT (Jufeng 2005ii; Lincoln
1984a; Smania 2006; Smith 1981ii; Wertz 1986i; Wu 2004),
intensive SLT (Smith 1981i), group SLT (Jufeng 2005i), volunteer-facilitated (MacKay 1988; Wertz 1986ii), computer-mediated SLT (Doesborgh 2004b; Katz 1997i; Katz 1997ii) and
functionally-based SLT involving a communicative partner (Lyon
1997).
Most participants randomised to the no SLT groups received no
interventions that included one active treatment or placebo either

preceded by or followed by conventional SLT. We were very fortunate that the unpublished individual patient data were available
for this review update. This access to the data, the design, nature
and manner of SLT delivery within the trial and the clinical relevance of the comparisons made it possible to include two paired
comparisons of those groups within the review:
SLT + Operant Training versus SLT + Social Support
(Lincoln 1982i);
Operant Training + SLT versus Social Support + SLT
(Lincoln 1982ii).
In addition, by taking the individual data at the point of measurement prior to the cross-over it was also possible to extract and
compare the data from those that had received conventional SLT
and compare it to those participants that received a social support
and stimulation intervention (Lincoln 1982iii).
We have presented data from 41 subcomparisons as they relate to
the effectiveness of SLT for aphasia following stroke, within three
comparisons: 1. SLT versus no SLT; 2. SLT versus social support
and stimulation; and 3. SLT A versus SLT B. We have presented
details of data within each comparison below with further details
on each subcomparison available in the Characteristics of included
studies table. Further participant details can be found in Table 1,
an overview of the SLT interventions can be found in Appendix 3 ,
while details of the assessment tools used can be found in Appendix
4. A summary of all the findings of the results is available at the
end of the results section.
alternative treatment or support (Doesborgh 2004b; Jufeng 2005i;
Jufeng 2005ii; Katz 1997i; Lincoln 1984a; Lyon 1997; MacKay
1988; Wertz 1986i; Wertz 1986ii; Wu 2004). Only four control
arms described an intervention within these no SLT groups. In
three cases we considered the control interventions to be similar
to standard post-stroke care in the UK - participants were visited
at home by a health visitor (Smith 1981i; Smith 1981ii) or they
received limb apraxia therapy (Smania 2006). In addition, a fourth
control group received computer-based cognitive tasks (arcadestyle games) (Katz 1997ii) that had been specifically designed not
to target language rehabilitation. In all four cases we included these
groups as no SLT control groups in the review.
SLT interventions were delivered across a wide range of times after
the onset of aphasia with timings difficult to summarise because
of a lack of detailed reporting. Some trialists recruited participants
in the early stages after the onset of stroke - up to 10 weeks (
Lincoln 1984a) or up to six months (Wertz 1986i; Wertz 1986ii).
Other trials recruited participants longer after stroke, for example
between two months and three years after stroke (Smania 2006).
In some trials participants were recruited a year or more after their
stroke - up to 17 months (Doesborgh 2004b); two years (MacKay
1988) (61% of participants); 10 years (13 to124 months) (Lyon

1997); 19 years (Katz 1997i); or up to 22 years (Katz 1997ii)

after the onset of aphasia. Five subcomparisons failed to report
the timing of the SLT intervention in relation to the onset of
participants aphasia (Jufeng 2005i; Jufeng 2005ii; Smith 1981i;
Smith 1981ii; Wu 2004).
The frequency of SLT was reported as hours per week or number of times daily. SLT was provided weekly for up to two
hours (Doesborgh 2004b; Lincoln 1984a; Smith 1981ii), three
hours (Katz 1997i; Katz 1997ii; Smania 2006), four hours (Smith
1981i), six hours (MacKay 1988), eight hours (Lyon 1997) or 10
hours (Wertz 1986i; Wertz 1986ii). SLT was provided daily (duration unclear) within two subcomparisons (Jufeng 2005i; Jufeng
2005ii) while Wu 2004 did not report the frequency of the SLT
intervention. All SLT was delivered for at least a month, but in
some cases SLT was provided for up to three months (Doesborgh
2004b; Jufeng 2005i; Jufeng 2005ii; Smania 2006; Wertz 1986i;
Wertz 1986ii); between five and six months (Katz 1997i; Katz
1997ii; Lincoln 1984a; Lyon 1997; Wu 2004) or for up to a year
(MacKay 1988; Smith 1981i; Smith 1981ii).
The subcomparisons used a wide range of outcome measures including functional communication, receptive language, expressive language, severity of impairment, psychosocial impact and
economic outcomes. One of the 14 subcomparisons did not report outcome measures (Wu 2004). Nine subcomparisons carried
out follow-up assessments at two months (Smania 2006), three
months (Jufeng 2005i; Jufeng 2005ii; Wertz 1986i; Wertz 1986ii),
six months (MacKay 1988) and 12 months (MacKay 1988) after
SLT.
2. SLT versus social support and stimulation
We included six subcomparisons in this section (David 1982;

Elman 1999; Lincoln 1982iii; Rochon 2005; Shewan 1984ii;
Shewan 1984iii) with 279 randomised participants.
A range of SLT approaches were reported including conventional
SLT (David 1982; Lincoln 1982iii; Shewan 1984iii), group SLT
(Elman 1999), language-oriented SLT (Shewan 1984ii) and sentence mapping SLT (Rochon 2005). The social support and stimulation interventions were provided by volunteers not known to
the participants with aphasia (David 1982), nursing staff (Shewan
1984ii; Shewan 1984iii), speech and language therapists (Lincoln
1982iii; Rochon 2005) or through other social group activities
including movement classes, creative arts groups, church activities
or support groups (Elman 1999). David 1982 provided the volunteers with detailed information on their patients communication
problems and they were instructed to encourage their patient to
communicate as well as possible. Similarly, the nursing staff volunteers (Shewan 1984ii; Shewan 1984iii) were given some information about aphasia and instructed to stimulate communication
to the best of their ability. In all three subcomparisons the volunteers were given no guidance or instruction in SLT techniques.
Participants were recruited with aphasia of various duration -
up to four weeks (Shewan 1984ii; Shewan 1984iii); up to three

years (David 1982; Lincoln 1982iii), seven months to 28 years
(Elman 1999) or between two and nine years (Rochon 2005).
Interventions were provided weekly for up to two (David 1982;
Lincoln 1982iii), three (Shewan 1984ii; Shewan 1984iii) or five
hours (Elman 1999) over the course of one (Lincoln 1982iii), four
(Elman 1999), five (David 1982) or 12 months (Shewan 1984ii;
Shewan 1984iii).
Outcome measures used in this comparison included measures
of functional communication, receptive language, expressive language and levels of severity of impairment. Two subcomparisons
carried out follow-up measures at four weeks (Rochon 2005), three
months and six months (David 1982) after the treatment period.
3. SLT A versus SLT B
We included 21 subcomparisons (732 randomised participants)

in this section (Bakheit 2007; Denes 1996; Di Carlo 1980;
Doesborgh 2004a; Drummond 1981; Hinckley 2001; Jufeng
2005iii; Leal 1993; Lincoln 1982i; Lincoln 1982ii; Lincoln
1984b; Meikle 1979; Meinzer 2007; ORLA 2006; Prins
1989; Pulvermuller 2001; Shewan 1984i; Smith 1981iii; van
Steenbrugge 1981; Wertz 1981; Wertz 1986iii). Three subcomparisons (Bakheit 2007; Prins 1989; Shewan 1984) also reported additional groups but participants were not adequately randomised to these groups and so they have been excluded from this
review.
A wide range of SLT interventions were reported including functional SLT (Hinckley 2001), intensive SLT (Bakheit 2007; Denes
1996; ORLA 2006; Smith 1981iii), volunteer-facilitated SLT
(Meikle 1979; Meinzer 2007; Leal 1993; Wertz 1986iii), group
SLT (Jufeng 2005iii; Pulvermuller 2001; Wertz 1981) and taskspecific SLT (Drummond 1981; Prins 1989; Pulvermuller 2001;
van Steenbrugge 1981; Shewan 1984i) compared to conventional
SLT. Other trials compared a semantic approach to SLT with
a phonological approach (Doesborgh 2004a) and filmed programmed instructions with non-programmed activity (Di Carlo
1980).
The duration of participants aphasia ranged from up to a month
(Leal 1993; Shewan 1984i; Smith 1981iii; Wertz 1981), two
months (Bakheit 2007), six months (Denes 1996; Doesborgh
2004a; Wertz 1986iii), a year (Lincoln 1984b), two years (
Drummond 1981), three years (Lincoln 1982i), five years (van
Steenbrugge 1981; Meikle 1979), six years (Di Carlo 1980;
Meinzer 2007), eight years (Hinckley 2001), 16 years (Kinsey
1986), 17 years (Prins 1989) or 19 years (Pulvermuller 2001) after
the onset of aphasia. Jufeng 2005iii did not report the duration of
their participants aphasia.
Therapy was provided daily (Jufeng 2005iii) for up to three
hours (Meinzer 2007; Pulvermuller 2001 ), or weekly for up
to 30 minutes (Drummond 1981), an hour (Lincoln 1984b),
one-and-a half hours (Lincoln 1982i; Smith 1981iii), two hours

(Prins 1989; van Steenbrugge 1981), three hours (Di Carlo

1980; Doesborgh 2004a; Leal 1993; Shewan 1984i), four hours
(Meikle 1979; Smith 1981iii), five hours (Bakheit 2007; Denes
1996), eight hours (Wertz 1981), 10 hours (Wertz 1986iii)
or 20 hours (Hinckley 2001). Therapy was provided for two
weeks (Drummond 1981), four weeks (Jufeng 2005iii), five weeks
(Hinckley 2001; Pulvermuller 2001), eight weeks (Lincoln 1982i,
Lincoln 1984b), nine weeks (van Steenbrugge 1981), 12 weeks
(Bakheit 2007; Wertz 1986iii), 16 weeks (Lincoln 1984b), 30
weeks (Di Carlo 1980), five months (Prins 1989), up to six months
(Denes 1996; Leal 1993), nine months (Doesborgh 2004a), 10
months (Wertz 1981), a year (Shewan 1984i, Smith 1981iii) or
two years (Meikle 1979).
There was a wide range of outcome measures used in this comparison including measures of functional communication, receptive language, expressive language, severity of impairment and psychosocial impact. Follow-up assessments were carried out at six
weeks (Wertz 1986iii) and three months (Jufeng 2005iii; Bakheit
2007) following treatment.
Excluded studies
We excluded 13 studies (Cherney 2007; Cohen 1992; Cohen
1993; Gu 2003; Hartman 1987; Jungblut 2004; Kagan 2001;
Kinsey 1986; Meinzer 2005; Rudd 1997; Wang 2004; Wolfe
2000; Zhang 2004). Three additional studies had been excluded
from the original review (Kalra 1993; Stoicheff 1960; Wood
1984). Reasons for exclusion were primarily due to inadequate
randomisation and the unavailability of aphasia specific data (see
details in the Characteristics of excluded studies table).
Risk of bias in included studies

Two review authors independently reviewed the methodological
quality of the included studies and resolved disagreements through
discussion. Details can be found in the Risk of bias tables for each
of the subcomparisons in the Characteristics of included studies
table.
The number of participants randomised across subcomparisons included in the review ranged from five to 327 participants. Three comparisons randomised 10 participants or fewer
(Drummond 1981; Rochon 2005; van Steenbrugge 1981). Eleven
randomised between 11 and 20 participants (Denes 1996; Di
Carlo 1980; Doesborgh 2004b; Hinckley 2001; Lincoln 1982i;
Lincoln 1982ii; Lincoln 1982iii Lincoln 1984b; Meinzer 2007;
Pulvermuller 2001). Eleven randomised up to 50 participants
(Elman 1999; Katz 1997i; Katz 1997ii; Lyon 1997; Meikle 1979;
Prins 1989; Shewan 1984iii; Smania 2006; Smith 1981i; Smith
1981ii; Smith 1981iii). Thirteen randomised between 51 and
100 participants (Bakheit 2007; Doesborgh 2004a; Jufeng 2005i;
Jufeng 2005ii; Jufeng 2005iii; Leal 1993; MacKay 1988; Shewan
1984i; Shewan 1984ii; Wertz 1981; Wertz 1986i; Wertz 1986ii;
Wertz 1986iii) and three randomised more than 150 participants

(David 1982; Lincoln 1984a; Wu 2004) (see Table 1).
Of the 41 subcomparisons, only 17 listed both inclusion and exclusion criteria. Details of exclusion criteria were unavailable for
19 subcomparisons (Denes 1996; Di Carlo 1980; Hinckley 2001;
Jufeng 2005i; Jufeng 2005ii; Jufeng 2005iii; Katz 1997i; Katz
1997ii; Lincoln 1984b; Lyon 1997; MacKay 1988; Meikle 1979;
ORLA 2006; Prins 1989; Rochon 2005; van Steenbrugge 1981;
Wertz 1981; Wertz 1986i; Wertz 1986ii; Wertz 1986iii) and two
listed neither inclusion nor exclusion criteria (Drummond 1981;
Wu 2004). For details, see the Characteristics of included studies
table.
Suitable statistical data for communication outcomes were only
available for 28 of the 41 subcomparisons (Bakheit 2007; David
1982; Denes 1996; Di Carlo 1980; Doesborgh 2004a; Doesborgh
2004b; Hinckley 2001; Jufeng 2005i; Jufeng 2005ii; Jufeng
2005iii; Katz 1997i; Katz 1997ii; Lincoln 1982i; Lincoln 1982ii;
Lincoln 1982iii; Lincoln 1984a; Lincoln 1984b; Meikle 1979;
Meinzer 2007; ORLA 2006; Prins 1989; Rochon 2005; Smania
2006; van Steenbrugge 1981; Wertz 1981; Wertz 1986i; Wertz
1986ii; Wertz 1986iii). An additional nine subcomparisons contributed data on the trial drop-outs or withdrawals. Psychosocial
data were available for one subcomparison (Lincoln 1984a). Appropriate statistical data were not provided or could not be extracted in the remaining three subcomparisons (Drummond 1981;
Lyon 1997; Wu 2004).
There was a wide range of variation in the descriptions of the SLT
interventions. Most reported the use of a conventional SLT approach (Bakheit 2007; Denes 1996; Drummond 1981; Hinckley
2001; Leal 1993; Lincoln 1982iii; Lincoln 1984b; Prins 1989;
Pulvermuller 2001; Shewan 1984i; Shewan 1984iii; Smania 2006;
Smith 1981i; Smith 1981ii; Smith 1981iii; van Steenbrugge 1981;
Wertz 1981; Wertz 1986i; Wertz 1986iii; Wu 2004) or described
an intervention which reflects clinical practice where the therapist was responsible for design and delivery of the treatment
(David 1982; Jufeng 2005i; Jufeng 2005ii; Jufeng 2005iii; Lincoln
1984a; Meikle 1979). Other more prescriptive SLT interventions
were also evaluated (Denes 1996; Doesborgh 2004a; Doesborgh
2004b; Drummond 1981; Elman 1999; Hinckley 2001; Katz
1997i; Katz 1997ii; Kinsey 1986; Lincoln 1982i; Lincoln 1982ii;
Lincoln 1984a; Lyon 1997; MacKay 1988; Meinzer 2007; ORLA
2006; Prins 1989; Pulvermuller 2001; Rochon 2005; Wertz 1981;
Shewan 1984i; Shewan 1984ii; Smith 1981iii; van Steenbrugge
1981) and these will be detailed further in later sections.
Twenty-four subcomparisons reported similar groups at baseline
(Bakheit 2007; Denes 1996; Di Carlo 1980; Doesborgh 2004b;
Drummond 1981; Elman 1999; Hinckley 2001; Katz 1997i; Katz
1997ii; Leal 1993; Lincoln 1982i; Lincoln 1984a; Meikle 1979;
Rochon 2005; Shewan 1984i; Shewan 1984ii; Shewan 1984iii;
Smania 2006; Smith 1981iii; van Steenbrugge 1981; Wertz 1981;
Wertz 1986i; Wertz 1986ii; Wertz 1986iii). Comparison between the groups at baseline was unclear in seven subcompar-

10
isons (Jufeng 2005i; Jufeng 2005ii; Jufeng 2005iii; Lincoln 1984b;

Lyon 1997; MacKay 1988; Wu 2004). For seven subcomparisons
the two groups differed despite randomisation in relation to their
time post-onset (Pulvermuller 2001), the severity of their aphasia
(Smith 1981i; Smith 1981ii) and age (David 1982; Doesborgh
2004a; Meinzer 2007; Prins 1989). In Meikle 1979 the participants that were allocated to SLT received more weeks of the intervention than the volunteer-facilitated group (P = 0.01).
Allocation
Details of the method of generating the randomisation sequence
were only available in nine of the 41 subcomparisons. Six used random numbers tables (Bakheit 2007; David 1982; Katz 1997i; Katz
1997ii; Lincoln 1984a; Smania 2006) and three were computergenerated (Doesborgh 2004a; Doesborgh 2004b; Pulvermuller
2001). The remaining 32 subcomparisons stated that participants
were randomly allocated but did not report any further details.
Four subcomparisons described stratifying participants by type
and severity of aphasia (Leal 1993; Shewan 1984i; Shewan 1984ii;
Shewan 1984iii).
Details of the allocation concealment were available for six of the
41 subcomparisons. Five used sequentially numbered sealed envelopes and were considered to be adequately concealed (Bakheit
2007; David 1982; Doesborgh 2004a; Doesborgh 2004b; Lincoln
1984a) but one described a trialist-led allocation method which inadequately concealed participant allocation to the groups (Smania
2006). Data from two subcomparisons (Smith 1981i; Smith
1981ii) are subgroups of participants with aphasia from within a
larger trial examining models of stroke care. The main trial described the inclusion of 20 participants with mild dementia but it
is unclear whether any of these individuals were included in the
aphasia-specific data.
Blinding
Due to the nature of SLT it is difficult to blind either the patient
or person carrying out the intervention. However, blinding of
the outcome assessor is possible and should be in place to avert
detection bias. More than half of the included subcomparisons
(23/41) reported blinding of the outcome assessors (Bakheit 2007;
Denes 1996; Doesborgh 2004a; Jufeng 2005i; Jufeng 2005ii;
Jufeng 2005iii; Lincoln 1982i; Lincoln 1982ii; Lincoln 1982iii;
Lincoln 1984a; MacKay 1988; Meinzer 2007; Pulvermuller 2001;
Shewan 1984i; Shewan 1984ii; Shewan 1984iii; Smania 2006;
Smith 1981i; Smith 1981ii; Smith 1981iii; Wertz 1981; Wertz
1986i; Wertz 1986ii; Wertz 1986iii; Wu 2004). In addition, David
Selective reporting
Two subcomparisons reported using intention-to-treat (ITT) analysis but not all participants appeared to be included in the fi-
1982 described blinding of outcome assessors but they also report

that this was confounded to some extent by indications from the
participants being assessed as to which group they were attending.
This is likely to have occurred in more than one trial. In other
cases blinding was partially in place - for example the assessor for
one of several outcome measures was blinded in Lincoln 1984b
while Katz 1997i and Katz 1997ii ensured blinding of a second
assessor who checked 95% of assessment scores. Blinding however
was unclear for eight subcomparisons (Di Carlo 1980; Doesborgh
2004b; Drummond 1981; Hinckley 2001; Leal 1993; Prins 1989;
Rochon 2005; van Steenbrugge 1981). Outcome assessors were
not blinded for three subcomparisons (Elman 1999; Lyon 1997;
Meikle 1979).
Incomplete outcome data
Overall just over a quarter of the 1840 participants randomised
across the studies included in this review withdrew or were lost to
follow up (431 participants plus 51 at follow up).
Of the 1064 participants in the SLT versus no SLT comparison, a
fifth (224) of participants withdrew from the treatment phase of
the studies (111 from the SLT interventions and 113 from the no
SLT allocation). In addition, 19 participants were lost during the
follow-up assessment phase (10 withdrawing from the SLT groups
and nine from the no SLT groups) and five more participants
withdrew after randomisation but it is unclear which group they
were allocated to (Smith 1981i; Smith 1981ii; Smith 1981iii).
The trials that compared SLT to social support and stimulation
randomised a total of 279 participants (David 1982; Elman 1999;
Lincoln 1982iii; Rochon 2005; Shewan 1984ii; Shewan 1984iii).
However, over a quarter of participants (83 participants) were
lost during the treatment phase (32 from the SLT group and 51
from the social support groups). Twenty-five additional participants were not included in the follow up (David 1982; Elman
1999).
The final comparison of SLT A versus SLT B involved 732 randomised participants; however a fifth (154 participants) withdrew
from the trials during the treatment phase with an additional 10
withdrawing from the follow-up phase. In one trial five participants were reported to have withdrawn from the overall trial but it
is unclear which subcomparison group(s) those participants were
allocated to (Smith 1981i; Smith 1981ii; Smith 1981iii). Participants in one subcomparison (Meikle 1979) remained in the trial
until two successful estimations on an outcome measure showed
no appreciable improvement, participants requested withdrawal
or until the end of the trial, however no further details were given.
Where available, details of drop-outs are presented in Table 2.
nal analyses (Bakheit 2007; Doesborgh 2004a). None of the 23
subcomparisons with participants who had dropped out from
the intervention or control groups used ITT analysis (Bakheit
2007; David 1982; Doesborgh 2004a; Doesborgh 2004b; Elman

11
1999; Katz 1997i; Katz 1997ii; Leal 1993; Lincoln 1982i; Lincoln
1984a; MacKay 1988; Meikle 1979; Shewan 1984i; Shewan
1984ii; Shewan 1984iii; Smania 2006; Smith 1981i; Smith 1981ii;
Smith 1981iii; Wertz 1981; Wertz 1986i; Wertz 1986ii; Wertz
1986iii). All randomised participants were included in the final
analyses for the remaining 15 subcomparisons.
Recruitment and retention of stroke rehabilitation trial participants is known to be a challenge and the trials in this review were
no exception. However, seven trials only reported data (including
demographic data) from participants that remained in the trial at
the end of treatment or at follow up. David 1982 reported data
from 133 of 155 randomised participants, Doesborgh 2004b reported 18 of 19 randomised participants, Katz 1997i reported
36 of 42 randomised participants, Katz 1997ii reported 40 of 42
randomised participants, Lincoln 1984a reported 191 of 327 randomised participants, MacKay 1988 reported 95 of 96 randomised
participants and Smania 2006 reported 33 of 41 randomised participants. More recently, to minimise the possibility of bias, trialists have been encouraged to report data from all randomised
participants.
being compared, treatment review processes were in place to ensure any possible risk of overlap in therapy approach was minimised. Being part of a larger stroke trial, participants in the Smith
1981iii trial also received other intensive treatment which may
have affected their levels of fatigue and ability to fully participate
in SLT intervention.
Effects of interventions
The results of this review are presented below within the three
comparisons: 1. SLT versus no SLT, 2. SLT versus social support
and stimulation and 3. SLT A versus SLT B. Where possible results from meta-analyses are also reported. As described within
the Measures of treatment effect section, we extracted the final
value scores for subcomparisons for inclusion within this review
whenever possible. Final values scores were available for 23 of the
41 subcomparisons and these have been included within the review. Change-from-baseline data were available for an additional
three subcomparisons (Denes 1996; Doesborgh 2004a; Hinckley
2001). Where change-from-baseline data are used they are clearly
marked and the data are not pooled within the meta-analyses with
final value scores.
Other potential sources of bias

Co-interventions were reported by some trialists that compared
the effects of SLT with no SLT but the number and allocation of
the participants and details of the intervention were unclear. For
example, some participants in Doesborgh 2004b also received psychosocial group therapy. Some (or all) of the participants reported
in Smith 1981i may have benefited from other intensive treatment
as part of the larger multi-disciplinary stroke trial. Three subcomparisons reported that not all participants received the planned
number of treatment sessions (Lincoln 1984a; Smith 1981i; Smith
1981ii).
Similarly, five subcomparisons that compared two different approaches to SLT provision reported that not all participants received the planned number of treatment sessions (Bakheit 2007;
Lincoln 1982i; Lincoln 1982ii; Meikle 1979; Smith 1981iii). In
one case (Meikle 1979) it was reported that five of the 16 participants receiving conventional SLT missed up to half of their
possible treatment. Two trials comparing intensive SLT with conventional SLT also reported difficulties providing intensive SLT
interventions as planned. Bakheit 2007 reported that only 13 of
the 51 participants received 80% or more of the planned intensive intervention. Smith 1981iii reported that participants allocated to intensive therapy only received an average of 21 hours
of therapy compared to the planned minimum of 50 hours during the first three months. Such difficulties in maintaining a clear
distinction between the two treatment groups has significant implications when evaluating the results and considering the clinical
implications of such treatment regimens.
Though all the speech and language therapists in Hinckley 2001
were trained in the characteristics of the two treatment approaches
Comparison 1: SLT versus no SLT

A total of 1064 participants were randomised across 14 subcomparisons that contrasted SLT with no SLT (Doesborgh 2004b;
Jufeng 2005i; Jufeng 2005ii; Katz 1997i; Katz 1997ii; Lincoln
1984a; Lyon 1997; MacKay 1988; Smania 2006; Smith 1981i;
Smith 1981ii; Wertz 1986i; Wertz 1986ii; Wu 2004). Reporting
of age and other descriptions of the participants across trials varied,
making it difficult to give an overview of the participants involved
in this comparison. Only four trials reported age ranges, spanning 38 to 92 years of age (Lincoln 1984a; Lyon 1997; Smania
2006; Wu 2004), while others reported participants mean age or
age bands. Details can be found in Table 1. Nine subcomparisons
gave an indication of the length of time since participants had
experienced the onset of their aphasia: the widest post-onset time
spanning from two to 36 months (Smania 2006). The shortest
mean length of time since the onset of participants aphasia was
between 6.6 and 7.8 weeks (Wertz 1986i; Wertz 1986ii). Severity
of aphasia was only reported by five subcomparisons (Doesborgh
2004b; Smith 1981i; Smith 1981ii; Wertz 1986i; Wertz 1986ii),
although two additional subcomparisons did provide some guide
to severity of impairment (Lyon 1997; Smania 2006).
Amongst the SLT interventions compared to a no SLT group
were interventions described as conventional SLT (Jufeng 2005ii;
Smania 2006; Smith 1981ii; Wertz 1986i; Wu 2004), computermediated SLT (Doesborgh 2004b; Katz 1997i; Katz 1997ii);
group SLT (Jufeng 2005i); functional SLT (Lyon 1997); intensive
SLT (Smith 1981i); SLT plus operant training (Lincoln 1984a)
and volunteer-facilitated SLT (MacKay 1988; Wertz 1986ii). We
planned to conduct a sensitivity analysis on subcomparisons that

12
involved the provision of SLT by non-speech and language therapists (Jufeng 2005i; Jufeng 2005ii; MacKay 1988; Wertz 1986ii)
but because of the present availability of data within each outcome
it was not useful to undertake this analysis.
Appropriate summary data for communication outcomes (allowing inclusion in the meta-analyses) were available for only nine of
the 14 subcomparisons (Doesborgh 2004b; Jufeng 2005i; Jufeng
2005ii; Katz 1997i; Katz 1997ii; Lincoln 1984a; Smania 2006;
Wertz 1986i; Wertz 1986ii). In addition, Lincoln 1984a also reported statistical data for psychosocial outcomes. Suitable summary data were not reported (or available on request) for the remaining five subcomparisons (Lyon 1997; MacKay 1988; Smith
1981i; Smith 1981ii; Wu 2004). Where data for this comparison
were available they are presented below in relation to the following: 1. functional communication; 2. receptive language; 3. expressive language; 4. severity of impairment; 5. psychosocial; 6.
number of drop-outs; 7. compliance with allocated intervention;
8. economic outcomes.
1. Functional communication
Eight of the 14 subcomparisons (Doesborgh 2004b; Katz 1997i;

Katz 1997ii; Lincoln 1984a; Lyon 1997; MacKay 1988; Wertz
1986i; Wertz 1986ii) compared participants that received SLT
to those randomised to no SLT by measuring functional communication outcomes. Five had suitable statistical data available
allowing inclusion within the meta-analyses (Doesborgh 2004b;
Katz 1997i; Katz 1997ii; Wertz 1986i; Wertz 1986ii). Tools used
included the spontaneous speech subtest of the Western Aphasia
Battery (WAB) (Katz 1997i; Katz 1997ii) and the Amsterdam-Nijmegen Everyday Language Test (ANELT-A) (Doesborgh 2004b),
the Communication Activities of Daily Living (CADL) (Wertz
1986i; Wertz 1986ii) and the Functional Communication Profile
(FCP) (Lincoln 1984a; Wertz 1986i; Wertz 1986ii).
Spontaneous speech
Three subcomparisons evaluated the impact of SLT by contrasting
the spontaneous speech of participants who received computermediated SLT with those who did not (Doesborgh 2004b; Katz
1997i) or those who received computer-mediated non-linguistic
tasks (Katz 1997ii). Comparisons were made using a subtest of
the WAB (Katz 1997i; Katz 1997ii) or the ANELT-A (Doesborgh
2004b). There was no evidence of a significant difference in the
measures of participants spontaneous speech abilities on these
measures though Doesborgh 2004b may demonstrate a trend towards better spontaneous speech skills in those participants that
had access to SLT than those that did not (P = 0.08, SMD 0.88,
95% CI -0.10 to 1.87) (Analysis 1.1).
Communication Activities of Daily Living (CADL)
Four subcomparisons used the CADL to compare the functional

communication skills of participants that received SLT (conventional SLT (Wertz 1986i), volunteer-facilitated SLT (MacKay
1988; Wertz 1986ii) and functional SLT (Lyon 1997)), and those
that received no SLT intervention. Two subcomparisons provided
statistical data which allowed inclusion within a meta-analysis
(Wertz 1986i; Wertz 1986ii). There was no evidence of a difference between the groups provided with SLT and those that were
not (Analysis 1.1).
Functional Communication Profile (FCP)
Three subcomparisons (Lincoln 1984a; Wertz 1986i; Wertz
1986ii) compared the pragmatic provision of SLT (approach tailored to individual participants needs) to a deferred SLT intervention using the FCP. Appropriate summary data for Lincoln
1984a on this outcome measure were not available. There was no
evidence of a difference between the groups.
In pooling the results of functional communication measures
within the meta-analysis only one set of functional communication measures from Wertz 1986i and Wertz 1986ii could be included at a time. Neither pooling approach provided evidence of
a difference between the groups (by including the CADL data P
= 0.16, SMD 0.19, 95% CI -0.13 to 0.50; including FCP data
P = 0.08, SMD 0.28, 95% CI -0.03 to 0.59). We have chosen
to present the data from the FCP within the forest plot (Analysis
1.1).
2. Receptive language
Five of the 14 subcomparisons measured participants receptive

language skills (Katz 1997i; Katz 1997ii; Smania 2006; Wertz
1986i; Wertz 1986ii) and all reported statistical data which permitted inclusion in the meta-analyses. Auditory comprehension
was measured using the Token Test, a WAB subtest and the Porch
Index of Communicative Abilities (PICA) subtest. Reading comprehension was measured using the Reading Comprehension Battery for Aphasia and the reading subtest of the PICA. Gesture
comprehension was measured using an unnamed assessment.
Auditory comprehension
Two subcomparisons used a subtest of the WAB to measure participants auditory comprehension (Katz 1997i; Katz 1997ii). There
was no evidence of a difference between the groups that received
computer-mediated SLT and those that did not. The same participants auditory comprehension skills were also measured on
a subtest of the PICA. Three subcomparisons used the Token
Test to measure changes in participants auditory comprehension
(Smania 2006; Wertz 1986i; Wertz 1986ii). As above, both sets
of data from Katz 1997i and Katz 1997ii could not be included
in the same meta-analysis. On pooling the data within two separate meta-analyses, neither demonstrated a significant difference

13
between the groups (by including the WAB data P = 0.59, SMD
0.08, 95% CI -0.21 to 0.38; by including the PICA data P = 0.52,
SMD 0.10, 95% CI -0.20 to 0.39). We have chosen to present
the PICA data within the forest plot (Analysis 1.2).
Reading comprehension
Reading comprehension was measured by four subcomparisons
(Katz 1997i; Katz 1997ii; Wertz 1986i; Wertz 1986ii) that compared participants that received SLT and those that did not. Two
trials used the Reading Comprehension Battery for Aphasia to
compare participants that received volunteer-facilitated SLT with
those that received no SLT (Wertz 1986i; Wertz 1986ii). Similarly, two trials used the PICA reading subtest to compare participants that received computer-mediated SLT to those that received
no treatment (Katz 1997i) or computer-mediated non-linguistic
tasks (Katz 1997ii). On pooling of the data there was no evidence
of a difference between the groups (Analysis 1.3).
Other comprehension
The PICA gestural subtest was used by four subcomparisons (Katz
1997i; Katz 1997ii; Wertz 1986i; Wertz 1986ii) and measures, not
just gestural abilities, but also tests auditory and written comprehension skills. Following pooling, participants that received SLT
had achieved higher scores on measures of gesture use than the
groups that received no SLT (P = 0.02, MD 8.04, 95% CI 1.55
to 14.52) (Analysis 1.4).
Gesture comprehension
Smania 2006 used an unnamed gesture comprehension assessment
tool to compare a group that received conventional SLT and those
that received limb apraxia therapy at two time points: after intervention and again two months later. There was no evidence of a
difference between the two groups comprehension of gestures at
either time point (Analysis 1.5).
3. Expressive language
Five of the 14 subcomparisons (Doesborgh 2004b; Katz 1997i;

Katz 1997ii; Wertz 1986i; Wertz 1986ii) formally evaluated participants expressive language skills using single word picture naming (Boston Naming Test and WAB naming subtests), repetition (WAB repetition subtest) and other verbal expression (PICA)
skills. Written language expressive skills were measured using the
PICA copying and writing subtests while the ability to communicate using gesture was measured using the PICA gesture subtest.
Expressive language: naming

Participants spoken language abilities were measured by three
subcomparisons (Doesborgh 2004b; Katz 1997i; Katz 1997ii).
Doesborgh 2004b used the Boston Naming Test to compare a
group receiving computer-mediated SLT and a group that did not
receive SLT. Similarly, Katz 1997i and Katz 1997ii employed the
WAB naming subtest. On pooling there was no evidence of a difference between the groups (Analysis 1.6).
Expressive language: general
Four subcomparisons used the PICA verbal subtest to compare the
spoken language skills of groups that received SLT and those that
did not (Katz 1997i; Katz 1997ii; Wertz 1986i; Wertz 1986ii).
There was no evidence of a between-group difference (Analysis
1.7).
Expressive language: written
Two subcomparisons compared a group receiving computer-mediated SLT to a group receiving no SLT (Katz 1997i) or a group
receiving computer-mediated non-linguistic tasks (Katz 1997ii)
using the PICA copying and writing subtests. Wertz 1986i and
Wertz 1986ii used the PICA Graphic subtests. Following pooling
there was no evidence of a difference between the groups on any
of these measures (Analysis 1.8).
Repetition
Katz 1997i and Katz 1997ii compared participants that received
computer-mediated SLT with participants that received no SLT
(Katz 1997i) and participants that received computer-mediated
non-SLT tasks (Katz 1997ii) using the WAB repetition test. Following pooling there was no evidence of a difference in the participants repetition skills on these measures (Analysis 1.9).
4. Severity of impairment
Ten subcomparisons compared participants that received SLT with

those that did not by measuring the severity of their aphasia
impairment using an aphasia quotient and language assessment
batteries (Jufeng 2005i; Jufeng 2005ii; Katz 1997i; Katz 1997ii;
Lincoln 1984a; Lyon 1997; Smith 1981i; Smith 1981ii; Wertz
1986i; Wertz 1986ii). Language assessment batteries included the
PICA, Boston Diagnostic Aphasia Examination (BDAE) and the
Minnesota Test for Differential Diagnosis of Aphasia (MTDDA).
Details of the Chinese Rehabilitation Research Centre Aphasia
Examination (CRRCAE) assessment were not available to us. We
were able to obtain suitable statistical summary data from these
outcome measures for six subcomparisons (Jufeng 2005i; Jufeng
2005ii; Katz 1997i; Katz 1997ii; Wertz 1986i; Wertz 1986ii).
Data from two subcomparisons that used the CRRCAE to compare participants aphasia following group SLT (Jufeng 2005i) or

14
one-to-one SLT (Jufeng 2005ii) with a group that received no

SLT were available. Four additional subcomparisons compared
groups that received computer-mediated SLT (Katz 1997i; Katz
1997ii), conventional SLT (Wertz 1986i) or volunteer-facilitated
SLT (Wertz 1986ii) to groups that received no SLT (Katz 1997i;
Wertz 1986i; Wertz 1986ii) or a computer-mediated non-SLT intervention (Katz 1997ii) using the PICA. On pooling, there was
no evidence of a difference between the groups that received SLT
and those that did not in measures of severity of aphasia impairment using either the Katz 1997i and Katz 1997ii PICA data (P
= 0.19) or the WAB data (P = 0.28). We have chosen to present
the PICA data (Analysis 1.10).
Jufeng 2005i and Jufeng 2005ii also repeated the comparison of
participants who received group SLT and conventional SLT with
those who had not received any SLT on measures of aphasia severity at a three-month follow up. The group that received group SLT
scored significantly higher than those that received no SLT but on
pooling (using a random-effects model in the presence of significant statistical heterogeneity) there was no evidence of a difference
between the groups (Analysis 1.11).
5. Psychosocial
Four subcomparisons compared the benefits of SLT intervention

to no SLT by employing psychosocial measures including the
Multiple Affect Adjective Checklist (MAAC), the General Health
Questionnaire (GHQ), the Affect Balance Scale and the Psychological Wellbeing Index (Lincoln 1984a; Lyon 1997; Smith 1981i;
Smith 1981ii).
Lyon 1997 used the Affect Balance Scale and Psychological Wellbeing Index to compare a group of triads (person with aphasia,
caregiver and communication partner) that received functional
SLT that aimed to establish and maximise effective means of communication between communication partners and a group that
received no SLT. Suitable summary data for these measures were
unavailable and so they could not be included in this meta-analysis. Similarly, the GHQ was used to compare groups that received
either intensive SLT (Smith 1981i) or conventional SLT (Smith
1981ii) with a group that received no treatment but no summary
data were available for inclusion in this analysis. Lincoln 1984a
used the anxiety, depression and hostility scales of the MAAC to
compare the psychosocial wellbeing of a group that received SLT
(determined by the therapist) with a group that received no SLT.
Comparison of the groups failed to show any evidence of a difference in the participants anxiety, depression or hostility as measured on these scales (Analysis 1.12).
6. Number of drop-outs
Much of the information relating to the numbers of participant

drop-outs (where they occurred) was available for all 14 subcomparisons (Doesborgh 2004b; Jufeng 2005i; Jufeng 2005ii; Katz
1997i; Katz 1997ii; Lincoln 1984a; Lyon 1997; MacKay 1988;

Smith 1981i; Smith 1981ii; Smania 2006; Wertz 1986i; Wertz
1986ii; Wu 2004).
There was a range of reasons for the attrition of participants from
the trials (see Table 2 for details). One-fifth of participants randomised to this comparison withdrew during the treatment phase
(229 participants) and an additional 19 participants were lost at
the follow-up phase from across 11 subcomparisons (Doesborgh
2004b; Katz 1997i; Katz 1997ii; Lincoln 1984a; MacKay 1988;
Smith 1981i; Smith 1981ii; Smania 2006; Wertz 1986i; Wertz
1986ii; Wu 2004). An additional five participants withdrew from
Smith 1981i and Smith 1981ii (group allocation is unclear but
these withdrawals are included in the number above) and they
failed to report the number of withdrawals from the no SLT group.
On pooling of the available data relating to drop-outs there was
no evidence of a difference between the groups (Analysis 1.13).
7. Compliance with allocated intervention
Only two (Doesborgh 2004b; Smania 2006) of the 11 subcomparisons reporting participant drop-outs also described the reasons
for the 25 participants withdrawal. Of these, a total of 12 participants were described as withdrawing because they were uncooperative or they refused the allocated treatment (all from Smania
2006) with seven withdrawing from the conventional SLT group
and five withdrawing from the no SLT group. Details can be found
in Table 2.
8. Economic outcomes
Only one of the 14 subcomparisons described the measurement

of economic outcomes using structured questionnaires (MacKay
1988) but neither the questionnaire nor the results were available
for this review.
Comparison 2: SLT versus social support and
stimulation
Six subcomparisons compared the provision of SLT to the provision of informal social support and stimulation amongst a total
of 279 participants (David 1982; Elman 1999; Lincoln 1982iii;
Rochon 2005; Shewan 1984ii; Shewan 1984iii). As described
above, the description of participant groups within trials was variable and so it is difficult to give a precise overview of the participants included in this comparison. Four subcomparisons described the participants age range, which spanned 18 to 85 years
(Elman 1999; Lincoln 1982iii; Rochon 2005; Shewan 1984ii;
Shewan 1984iii). David 1982 reported participants in the SLT
and social support and stimulation groups had a mean age of 70
(8.7) and 65 (10.6) years respectively, indicating a significant difference between the groups (P = 0.003). Details can be found in
Table 1. All five subcomparisons detailed the length of time since
the onset of participants aphasia. Participants with the most acute

15
aphasia were recruited to Shewan 1984ii and Shewan 1984iii with

aphasia that was between two and four weeks since onset. In contrast, Lincoln 1982iii recruited participants between one and 36
months post-stroke while some of the other trials recruited participants much later following stroke with ranges from two to nine
years (Rochon 2005) or seven months to 28 years (Elman 1999).
Severity of aphasia was reported by all six subcomparisons in varying degrees of detail. Lincoln 1982iii recruited participants with
moderate degrees of aphasia. The remaining five subcomparisons
described the recruitment of participants with a range of mild to
severe aphasia impairments (David 1982; Elman 1999; Rochon
2005; Shewan 1984ii; Shewan 1984iii) (see Table 1 for details).
There were a number of approaches to the provision of SLT interventions in the trials: four provided conventional SLT (David
1982; Elman 1999; Lincoln 1982iii; Shewan 1984iii) and the
others provided sentence-mapping SLT (Rochon 2005) and language-orientated SLT (Shewan 1984ii). These SLT interventions
were then compared to the provision of social support and stimulation which also took a variety of formats. The unstructured
support and communicative stimulation was provided by nurses
(Shewan 1984ii; Shewan 1984iii), other volunteers (David 1982),
speech and language therapists (Lincoln 1982iii; Rochon 2005)
or through attendance at an externally organised support group or
class, for example dance classes or church groups (Elman 1999).
Volunteers had been given detailed information about their own
participants particular presentation of aphasia but were not given
any training in SLT techniques. Lincoln 1982iii had a specific
non-therapeutic intervention protocol for the therapists whose
role was to have semi-structured conversations with the participant on a series of predetermined topics. The participants in these
groups received this support for one hour (Rochon 2005), two
hours (David 1982; Lincoln 1982iii) or three hours (Elman 1999;
Shewan 1984ii; Shewan 1984iii), each week over a period of a
month (Lincoln 1982iii), two-and-a-half months (Rochon 2005),
four months (Elman 1999), five months (David 1982) or a year
(Shewan 1984ii; Shewan 1984iii).
Statistical data for communication outcomes were available for
half the included subcomparisons (David 1982; Lincoln 1982iii;
Rochon 2005). Suitable data allowing inclusion within the metaanalyses were unavailable for the remaining three subcomparisons
(Elman 1999; Shewan 1984ii; Shewan 1984iii). The comparisons
made (with meta-analysis where possible) are reported below as
they relate to measures of: 1. functional communication; 2. receptive language; 3. expressive language; 4. severity of impairment;
5. psychosocial; 6. number of drop-outs; 7. compliance with allocated intervention. Economic outcomes were not measured.
1. Functional communication
Two subcomparisons measured functional communication (David

1982; Elman 1999) using the Functional Communication Profile
(FCP), the Communication Abilities of Daily Living (CADL) and
the Communicative Effectiveness Index (CETI).
Functional Communication Profile

David 1982 used the FCP to compare a group who received conventional SLT with a group that received communication treatment by volunteers. There was no evidence of a difference between
the groups nor was there any evidence of a difference at three and
six-month follow up (Analysis 2.1).
Communication Abilities of Daily Living and the

Communicative Effectiveness Index
Elman 1999 used the CADL, the CETI and measures of connected speech to compare the functional communication skills of
participants that received conventional SLT and those that did not
but who attended social groups and activities instead. No suitable
summary data were provided and so the data could not be included
in the meta-analysis.
2. Receptive language
Four of the six subcomparisons that compared participants that

received SLT or a social support and stimulation intervention did
so by comparing the groups receptive language skills (Lincoln
1982iii; Rochon 2005; Shewan 1984ii; Shewan 1984iii). Measures
used included the Philadelphia Comprehension Battery (PCB),
the Auditory Comprehension Test for Sentences (ACTS), the Token Test and the PICA Gestural subtest.
Philadelphia Comprehension Battery

Rochon 2005 measured participants receptive language skills on
the PCB, which includes subtests for sentence comprehension and
picture comprehension. There was no evidence of a difference between the receptive language skills of the participants that received
sentence-mapping SLT and those that received unstructured social
support and stimulation (Analysis 2.2).
Auditory Comprehension Test for Sentences (ACTS)

Two additional subcomparisons also measured receptive language
skills of a group that received either language-oriented therapy
(Shewan 1984ii) or conventional SLT (Shewan 1984iii) and compared their language reception to participants that received an intervention that provided unstructured social support. Both subcomparisons used the ACTS to make this comparison but the
manner in which the data are reported prevented inclusion within
the meta-analysis (Analysis 2.2).

16
Token Test
Lincoln 1982iii measured participants receptive language skills
using the Token Test. There was no evidence of a difference between the groups (Analysis 2.2).
treated and untreated items but there was no evidence of a between-group difference on the treated or untreated items (Analysis
2.6).
Expressive language: general

Participants auditory and written comprehension skills were measured using the PICA Gestural subtest by Lincoln 1982iii and
those that had access to social support and stimulation performed
significantly better on these measures than those that had access
to SLT (P = 0.04, MD -0.87, 95% CI -1.70 to -0.04) (Analysis
2.3).
Lincoln 1982iii and Elman 1999 compared the groups performances on the PICA verbal subtest. Suitable statistical data were
unavailable from Elman 1999 and so it could not be included
in the meta-analysis. Participants that had received social support
and stimulation scored significantly better than those that received
SLT (P = 0.0007, MD -1.56, 95% CI -2.46 to -0.66) (Analysis
2.7).
3. Expressive language
Three of the six subcomparisons that compared participants that

received SLT or a social support and stimulation intervention did
so by comparing the groups expressive language skills (Elman
1999; Lincoln 1982iii; Rochon 2005). Measures used included
the Object Naming Test (ONT), Caplan and Hanna Sentence
Production Test (CHSPT), the Picture Description with Structured Modeling (PDSM) and the PICA.
Similarly, Lincoln 1982iii compared the groups performances on

the PICA graphic subtests and found participants that received
social support performed significantly better than those that had
received SLT (P = 0.01, MD -1.39, 95% CI -2.49 to -0.29) (
Analysis 2.8).
Receptive language: other comprehension
Expressive language: single words

Lincoln 1982iii measured participants naming skills on the ONT
and a word fluency test and found those participants that received
social support and stimulation performed significantly better on
these tests than those that had received conventional SLT (P =
0.003, MD -7.00, 95% CI -11.67 to -2.33, and P < 0.0001, MD
-14.00, 95% CI -20.35 to -7.65 respectively) (Analysis 2.4).
Expressive language: sentences

Rochon 2005 compared the participants who received sentencemapping SLT and a group receiving unstructured social support
and stimulation. Comparison of the two groups showed no evidence of a difference between the groups performance on the
Caplan and Hanna Sentence Production Test scores. Those that
had received SLT did perform significantly better on treated items
from the test (P = 0.01, MD 3, 95% CI 0.63 to 5.37) than the participants that received social support but there was no evidence of
a difference between the groups on the untreated items (Analysis
2.5).
4. Severity of impairment
Elman 1999, Lincoln 1982iii, Shewan 1984ii and Shewan 1984iii

compared groups that had access to SLT and those that received
social support and stimulation by measuring participants aphasia
severity. The assessments used included the PICA and the Western
Aphasia Battery-Aphasia Quotient (WAB AQ).
PICA
Two subcomparisons used the Shortened PICA to compare participants that had received group SLT and those that had attended
other social activities or groups that provided social support and
stimulation (Elman 1999; Lincoln 1982iii). Suitable statistical
data were unavailable from Elman 1999 and so it could not be
included in the meta-analysis. Lincoln 1982iii found that participants provided with social support and stimulation were less impaired as a result of aphasia (as measured on the PICA) than those
that received SLT (P = 0.005, OR 0.65, 95% CI 0.38 to 1.12).
Suitable summary data were not available from Elman 1999 to
allow inclusion within the meta-analysis (Analysis 2.9).
WAB
Expressive language: picture description
Two subcomparisons elicited samples of participants connected
speech using picture description tasks (Lincoln 1982iii; Rochon
2005). There was no evidence of a difference between the two
groups. Rochon 2005 also reported the two groups scores on the
Two additional subcomparisons (Shewan 1984ii; Shewan 1984iii)

also compared groups based on the severity of participants aphasia using the WAB. They compared participants who received
language-oriented SLT (Shewan 1984ii) or conventional SLT
(Shewan 1984iii) with a group who received psychological support and unstructured communication provided by trained nurses.

17
Suitable summary data were unavailable and so it could not be

included in the meta-analysis.
5. Psychosocial
Elman 1999 compared participants that had received SLT and

those that had received social support and stimulation using measures of psychosocial impact using the Affect Balance Scale but
appropriate summary values were unavailable and so it could not
be included in the review.
6. Number of drop-outs
Drop-outs were reported by five of the six subcomparisons in

this section (David 1982; Elman 1999; Lincoln 1982iii; Shewan
1984ii; Shewan 1984iii). In the main Lincoln 1982 trial (from
which the subcomparison Lincoln 1982iii has been extracted) 13
participants were excluded for failing to complete the full treatment intervention. It is unclear which intervention arms these
participants were randomised to and so these drop-outs cannot
be included in this meta-analysis. In the remaining subcomparisons, a total of 44 participants were lost to the groups allocated
to SLT (32 from treatment and 12 at follow up) while 64 were
lost to the social support and stimulation interventions (45 during the intervention and 11 at follow up). There was no evidence
of a significant difference in the drop-out rates between the two
groups although there seems to be a consistency in the direction of
drop-outs, with a suggestion of better retention of participants in
the groups given SLT but this did not reach significance (Analysis
2.10).
7. Compliance with allocated intervention
Four subcomparisons that experienced drop-outs from their trial

also described the reasons for the drop-outs so that those who had
voluntarily withdrawn from the allocated intervention can be identified. A total of five participants withdrew from the groups that
received SLT while eight participants withdrew from the groups
that were allocated to receive social support and stimulation interventions (David 1982; Shewan 1984ii; Shewan 1984iii). Elman
1999 reports one withdrawal from the SLT group and two withdrawals from the social support and stimulation group because of
time constraints. In addition, David 1982 also describes the withdrawal of four more participants from the social support group
because of volunteer problems. Details can be found in Table 2.
Comparisons: SLT A versus SLT B
A total of 719 participants were randomised across 21 subcomparisons that compared one SLT intervention (SLT A) with another SLT intervention (SLT B) (Bakheit 2007; Denes 1996;
Di Carlo 1980; Doesborgh 2004a; Drummond 1981; Hinckley
2001; Jufeng 2005iii; Leal 1993; Lincoln 1982i; Lincoln 1982ii;
Lincoln 1984b; Meikle 1979; Meinzer 2007; ORLA 2006; Prins

1989; Pulvermuller 2001; Shewan 1984i; Smith 1981iii; van
Steenbrugge 1981; Wertz 1981; Wertz 1986iii). As within other
sections of this review, descriptions of the participants age and
other characteristics across trials varied. Participants age ranges
spanning 17 to 92 years were available for 13 subcomparisons while
the remaining reported mean age (Denes 1996; Doesborgh 2004a;
Drummond 1981; Hinckley 2001; Leal 1993; Smith 1981iii;
Wertz 1986iii) or participants within age bands (Jufeng 2005iii).
See Table 1 for details. All but two subcomparisons (Jufeng 2005iii;
Smith 1981iii) reported the length of time since their participants had experienced the onset of aphasia, ranging from within a
month of stroke onset (Bakheit 2007; Leal 1993; Shewan 1984i;
Wertz 1981), within approximately six months of stroke (Denes
1996; Di Carlo 1980; Doesborgh 2004a; Lincoln 1982i; Lincoln
1982ii; Lincoln 1984b; Meinzer 2007; Wertz 1986iii), or up to
a year or more after stroke (Drummond 1981; Hinckley 2001;
Meinzer 2007; ORLA 2006; Pulvermuller 2001; Prins 1989; van
Steenbrugge 1981).
Similarly, almost all subcomparisons reported the severity of aphasia with only two failing to give an indication of how severe participants aphasia was (Drummond 1981; Jufeng 2005iii). In most
cases subcomparisons reported the range of participants aphasia
severity as measured on a suitable assessment tool but in some
cases this was reported in more general terms (details can be found
in Table 1). Some subcomparisons focused specifically on participants with severe aphasia (Denes 1996; Di Carlo 1980; Lincoln
1984b) while others focused on moderate to severe presentations
of aphasia (Lincoln 1982i; Leal 1993).
Most of the subcomparisons included in this section compared
an experimental approach to the delivery of SLT to a conventional SLT intervention. These included a comparison of functional SLT (Hinckley 2001), intensive SLT (Bakheit 2007; Denes
1996; Smith 1981iii), group SLT (Jufeng 2005iii; Wertz 1981),
task-specific approaches to SLT (Drummond 1981; Prins 1989;
Pulvermuller 2001; Shewan 1984i; van Steenbrugge 1981) and
volunteer-facilitated SLT (Leal 1993; Meikle 1979; Wertz 1986iii)
with conventional SLT.
Additional comparisons included in this section are SLT with operant training (Lincoln 1982i) or SLT with programmed instruction and operant training (Lincoln 1984b) compared to conventional SLT (with a placebo attention intervention), semantic approaches to SLT compared with phonological approaches to SLT
(Doesborgh 2004a) and filmed programmed instructions compared with non-programmed activities (Di Carlo 1980).
Only 14 of the 21 subcomparisons reported suitable summary
data that permitted inclusion in the meta-analyses (Bakheit 2007;
Denes 1996; Di Carlo 1980; Doesborgh 2004a; Hinckley 2001;
Jufeng 2005iii; Lincoln 1982i; Lincoln 1982ii; Lincoln 1984b;
Meinzer 2007; ORLA 2006; Prins 1989; van Steenbrugge 1981;
Wertz 1986iii). Where data for this comparison were available they
are presented below within the comparisons: 3. Functional SLT

18
versus Conventional SLT; 4. Intensive SLT versus Conventional

SLT; 5. Volunteer-facilitated SLT versus Conventional SLT; 6.
Group SLT versus Conventional SLT; 7. Task-specific SLT versus
Conventional SLT; 8. Operant training SLT versus Conventional
SLT; 9. Semantic SLT versus Phonological SLT; 10. Programmed
instruction versus Non-programmed instruction. (Note: for consistency with the analyses this list starts at number 3).
required to complete the tasks with or without a concurrent task.

Participants that received the functional SLT performed significantly better on the spoken telephone order task (no concurrent
task P = 0.0001, MD 32.80, 95% CI 16.16 to 49.44; with concurrent task P = 0.03, MD 16.90, 95% CI 1.31 to 32.49) than
the participants that received the conventional SLT intervention.
There was no evidence of any difference between the groups performance on the written order tasks (Analysis 3.2).
3. Functional SLT (SLT A) versus conventional SLT (SLT B)
Hinckley 2001 was the only subcomparison identified that contrasted a group receiving functional SLT with a group who received conventional SLT in relation to participants (a) functional
communication and (b) expressive language. They did not address
participants receptive language skills, severity of impairment, psychosocial or economic outcomes. No participants were lost during
the interventions and so comparisons in relation to number of
drop-outs and compliance with allocated intervention could not
be made.
(a) Functional communication

Participants functional communication skills were measured on
the CADL and the CETI in order to compare the impact of a
functional SLT approach and a conventional SLT approach.
CADL
Hinckley 2001 only reported the participants change-from-baseline scores which demonstrated that participants in the conventional SLT group performed significantly better on the CADL
than those participants in the functional SLT group (P = 0.001,
MD -9.30, 95% CI -15.01 to -3.59) (Analysis 3.1).
CETI
The CETI was used by Hinckley 2001 to compare the groups
functional communication skills as perceived by their carer. Using
final value scores there was no evidence of a difference in the carers
ratings of the participants functional communication skills based
on whether they had access to functional SLT or a conventional
SLT intervention (Analysis 3.1).
Functional communication: catalogue ordering

Hinckley 2001 also developed a functional catalogue ordering task
to compare the two groups functional communication skills using change-from-baseline scores. Participants were required to order clothes from a catalogue by telephone (spoken modality) or
in writing (written modality). In each modality participants were
(b) Expressive language

Hinckley 2001 used the PALPA to compare the expressive language skills (oral and written) of participants that received either
functional SLT or conventional SLT. There was no evidence of a
difference between the groups oral naming change-from-baseline
scores (Analysis 3.3) or their written naming change-from-baseline scores (Analysis 3.4) on the PALPA measure
4. Intensive SLT (SLTA) versus conventional SLT (SLTB)
Four subcomparisons compared intensive SLT to conventional

SLT (Bakheit 2007; Denes 1996; ORLA 2006; Smith 1981ii).
The number of weekly hours in therapy for participants in the
Intensive SLT groups ranged from four hours (Smith 1981ii), five
hours (Bakheit 2007; Denes 1996), to 10 hours (ORLA 2006)
each week while the conventional SLT groups received 80 minutes
(Smith 1981iii), two hours (Bakheit 2007), three hours (Denes
1996) or four hours (ORLA 2006) each week. Statistical data for
communication outcomes were only available for three subcomparisons (Bakheit 2007; Denes 1996; ORLA 2006) and comparisons were made by measuring participants (a) receptive language,
(b) expressive language, (c) severity of impairment, (d) psychosocial impact, (e) number of drop-outs and (f ) compliance with allocated intervention. Functional communication and economic
outcome measures were not used.
(a) Receptive language

Measures of participants receptive language skills were only available for Denes 1996. Participants auditory comprehension was
measured using the Aachen Aphasia Test (AAT) Comprehension
subtest and the Token Test. Only change-from-baseline scores were
available. Comparison of the groups comprehension skills failed
to show a difference between those that had received intensive SLT
and those that had received conventional SLT on this measure, although the groups performance on the AAT Comprehension subtest indicated a trend towards better comprehension skills amongst
those participants that had received intensive SLT than those that
had received conventional SLT (P = 0.06) (Analysis 4.1).

19
(b) Expressive language
Expressive language: spoken

Denes 1996 measured expressive language skills using the AAT
Naming and Repetition subtests. Comparison of the groups
change from baseline scores showed no evidence of a difference
between those that received intensive SLT and those that received
conventional SLT on either of these measures (Analysis 4.2).

Denes 1996 used the AAT written subtest to compare changesfrom-baseline in participants written language (including reading
aloud and writing subtests). The group that was given intensive
SLT achieved significantly higher scores on this subtest than the
group that received conventional SLT intervention (P = 0.01, MD
8.9, 95% CI 1.81 to 15.99) (Analysis 4.3).
(c) Severity of impairment
Three subcomparisons (Bakheit 2007; Denes 1996; ORLA 2006)
compared participants overall level of aphasia severity following
intensive or conventional SLT by using the WAB and the Aachen
Aphasia Test (AAT). Smith 1981iii also measured aphasia severity
using the Minnesota Test for Differential Diagnosis of Aphasia
(MTDDA) but suitable statistical data allowing inclusion in the
meta-analysis were unavailable. There was no evidence of a difference between the groups that received intensive SLT and those
that received conventional SLT on these WAB final value scores
(Bakheit 2007; ORLA 2006) or AAT change-from-baseline scores
(Denes 1996) of severity either immediately post-treatment or at
three-month follow up (Bakheit 2007) (Analysis 4.4).
(d) Psychosocial
Smith 1981iii used the General Health Questionnaire to compare
groups receiving intensive SLT and conventional SLT. Appropriate
summary data for these groups were unavailable and so the results
could not be presented here.
(e) Number of drop-outs
Data relating to number of participants that dropped out of the
subcomparisons were available for Bakheit 2007, Denes 1996 and
ORLA 2006 and were partially available for Smith 1981iii. No
participants appear to have been lost from the treatment or followup time points in the Denes 1996 or ORLA 2006 studies. Five
additional participants were excluded from the final analysis in
Smith 1981iii (three were found not to have aphasia and two
died) but their group allocation was unclear. These data were not
included in this overview. Across the subcomparisons significantly
more participants (30 participants) were lost to the intensive SLT
groups in comparison to those lost to the conventional SLT groups
(17 participants) (P = 0.05, OR 2.10, 95% CI 0.99 to 4.46). Of
these, some were lost at follow up, with little difference between the
three participants lost from intensive SLT and the four participants
lost from the conventional SLT group in the Bakheit 2007 study
(Analysis 4.5).
(f ) Compliance with allocated intervention
Only Bakheit 2007 reported (in part) the reasons for loss of participants from within the study. Of these, one participant voluntarily withdrew from the intensive SLT group during the treatment
phase while none withdrew from the conventional SLT group.
5. Volunteer-facilitated SLT (SLTA) versus professional SLT

(SLTB)
Four subcomparisons compared participants that received volunteer-facilitated SLT and participants that received professional SLT
provided directly in a clinical setting by a professional therapist
(Leal 1993; Meikle 1979; Meinzer 2007; Wertz 1986iii). In most
cases professional SLT was delivered by a speech and language
therapist (Leal 1993; Meikle 1979; Wertz 1986iii) though delivery of the constraint-induced SLT intervention in Meinzer 2007
was delivered by a specialist psychologist. We believed that this
trial was suitable for inclusion in this comparison as it compared
interventions delivered by a professional clinician with delivery
facilitated by a trained volunteer.
Most volunteers were family members (Leal 1993; Meinzer 2007;
Wertz 1986iii) although some trialists also engaged friends (Wertz
1986iii) or recruited volunteers unknown to the participants
(Meikle 1979; Wertz 1986iii). Volunteer groups across the trials
all received SLT training, information on their patients communication impairment, access to working materials or equipment,
and ongoing support or supervision. Most studies indicated that
the professional therapist was accountable for, or informed the design and content of the volunteer-facilitated SLT (Meikle 1979;
Meinzer 2007; Wertz 1986iii).
The professional therapists were based in a formal or clinical setting (Leal 1993; Meikle 1979; Meinzer 2007; Wertz 1986iii). The
duration of the professional SLT interventions varied from three
hours daily for 10 consecutive days (Meinzer 2007) or up to three
hours (Leal 1993), four hours (Meikle 1979) or 10 hours weekly
for approximately three months (Wertz 1986iii), six months (Leal
1993) or an average of nine months (SD 22 weeks) (Meikle 1979).
The duration of volunteer-facilitated SLT and professionally-delivered SLT was the same for two subcomparisons (Meinzer 2007;
Wertz 1986iii). The volunteers in Meikle 1979 visited participants
four times weekly over a shorter period of time (average of five
months (SD 13.5 weeks)) while the duration of the volunteerfacilitated SLT in Leal 1993 is unclear. The four subcomparisons
used a range of measures to compare volunteer-facilitated SLT
with professional SLT delivery including (a) functional communication, (b) receptive language, (c) expressive language, (d) written
language, (e) severity of impairment, (f ) number of drop-outs and
(g) compliance with allocation.

20

Only Wertz 1986iii formally measured the functional communication skills of the participants that received volunteer-facilitated
SLT or professional SLT using the CADL and the Functional
Communication Profile. There was no evidence of a difference
(b) Receptive language
SLT and those that received professional SLT. There was no evidence of a difference between the groups (Analysis 5.5).
Expressive language: repetition

The group that received the volunteer-facilitated SLT intervention
scored significantly higher on the Repetition subtest (AAT) than
those that received SLT from a professional therapist (P = 0.05,
MD 13.50, 95% CI 0.19 to 26.81) (Meinzer 2007) (Analysis 5.6).
Receptive language: auditory comprehension

Three subcomparisons evaluated participants language comprehension abilities using the Token Test (Leal 1993; Meinzer 2007;
Wertz 1986iii) but suitable statistical data were unavailable for
Leal 1993. Meinzer 2007 also used the AAT to measure Auditory and Reading comprehension skills. Meinzer 2007 and Wertz
1986iii used the Token Test to measure differences in the auditory
comprehension of participants that received volunteer-facilitated
SLT and those that received professional therapy input. There was
no significant difference between the two groups auditory comprehension (Analysis 5.2). The comprehension subtest of the AAT
measures both auditory and reading comprehension and was used
by Meinzer 2007 to compare a group receiving volunteer-facilitated SLT or SLT delivered by experienced professionals. There
was no evidence of a difference between the groups comprehension on this measure (Analysis 5.2).
Receptive language: reading comprehension (RCBA)

Wertz 1986iii measured participants reading comprehension using the Reading Comprehension Battery for Aphasia. There was

The written language subtest of the AAT measures reading aloud
and writing to dictation. Meinzer 2007 compared the groups that
received volunteer-facilitated SLT and those that received professionally delivered SLT using this measure. Similarly, Wertz 1986iii
used the PICA Graphic subtest to compare the groups but found
no evidence of a difference (Analysis 5.7).
(d) Severity of impairment

Four subcomparisons compared the two groups using measures
of overall severity of aphasia following either volunteer-facilitated
SLT or professional SLT using the PICA (Meikle 1979; Wertz
1986iii), an aphasia quotient (Leal 1993) and the AAT profile
(Meinzer 2007). Summary data from the groups performance was
unavailable for Leal 1993 preventing inclusion within the review.
There was no evidence of a difference between the two groups
following pooling of data from the PICA and AAT profile (Analysis
5.8).

Receptive language: other
Wertz 1986iii compared participants receptive language skills using the PICA Gestural subtest. There was no evidence of a difference between the groups (Analysis 5.4).
(c) Expressive language

Meinzer 2007 measured expressive language skills using the Naming subtests of the AAT while Wertz 1986iii used the PICA Verbal
Subtest to compare participants that received volunteer-facilitated
All four subcomparisons reported the number of participants that

were lost to the trial following randomisation. Across three subcomparisons a total of 30 participants were lost from the groups
that experienced volunteer-facilitated SLT while 22 participants
were lost from the groups that received professional SLT interventions (Leal 1993; Meikle 1979; Wertz 1986iii). Meinzer 2007
experienced no participant withdrawals. An additional participant
that had received volunteer-facilitated SLT and two participants
that had received professional SLT were lost at follow up (Wertz
1986iii). No participants were reported lost at follow up from
Leal 1993. Overall, there was no evidence of a difference in the
numbers of drop-outs between the groups that received volunteerfacilitated SLT and those that had professionally delivered SLT
(Analysis 5.9).

21

Only two of the three trials provided details for participant withdrawals (Leal 1993; Meikle 1979). Overall, five participants declined to continue participating in the volunteer-facilitated SLT
groups while four declined in the professional SLT groups.
pooling these data with the Token Test data from the Pulvermuller
2001 comparison, there was no evidence of a difference between
the groups auditory comprehension skills, nor was there any indication of a difference between the groups on the AAT comprehension subtest (Pulvermuller 2001) (Analysis 6.1).
6. Group SLT (SLTA) versus one-to-one SLT (SLT B)
Three subcomparisons compared group SLT to conventional oneto-one SLT (Jufeng 2005iii; Pulvermuller 2001; Wertz 1981).
Within the group SLT interventions, participants received SLT in
groups of three plus a therapist (Pulvermuller 2001), between three
to seven (Wertz 1981) or 10 patients (Jufeng 2005iii). Participants
allocated to group SLT in Pulvermuller 2001 received a constraintinduced approach to SLT (only verbal responses were allowed). In
contrast, the group SLT intervention in Wertz 1981 encouraged
group discussion and recreational activities with a therapist while
Jufeng 2005iii focused on collective language strengthening training. In all cases the patients in the one-to-one SLT intervention
received conventional SLT (stimulus-response treatment across all
modalities). Between-intervention comparisons were made on a
variety of measures: (a) functional communication, (b) receptive
language, (c) expressive language, (d) severity of impairment, (e)
number of drop-outs and (f ) compliance with allocated intervention. Psychosocial and economic measures were not compared.
Wertz 1981 used the PICA Gestural Subtest to compare participants that had received group SLT and those that had received
one-to-one SLT. Though the mean values were available to the
review the SD values were unavailable. A standard deviation value
(25.67) was identified and imputed from Wertz 1986 where the
highest of three possible values in this trial from relevant clinical
groups was chosen to facilitate inclusion of the study within the
review (Analysis 6.2).

Two subcomparisons measured change in functional communication using the Communicative Activity Log (CAL) (Pulvermuller
2001), the Conversational Rating Scale (Wertz 1981) and the Informants Rating of Functional Language (adapted form of the
Functional Communication Profile) (Wertz 1981). However, suitable statistical data were unavailable and so could not be included
within the review.

Pulvermuller 2001 and Wertz 1981 measured participants expressive language skills using the naming subtest of the AAT, measures
of word fluency, and the PICA verbal subtest. Using the AAT naming subtest Pulvermuller 2001 found no evidence of a difference
between the groups expressive language skills (Analysis 6.3). Wertz
1981 used the verbal subtest of the PICA to measure participants
language comprehension skills. The mean scores of participants
that received group SLT and those that received one-to-one SLT
were available but SD data were not. A standard deviation value
(20.01) was identified and imputed from Wertz 1986 where the
highest of three possible values in this trial from relevant clinical
groups was chosen to facilitate inclusion of the study within the
review (Analysis 6.3). There was no evidence of a difference between the groups.

Expressive language: word fluency
Two subcomparisons measured participants receptive language
skills using the Token Test (Pulvermuller 2001; Wertz 1981) and
the language comprehension subtest of the AAT (Pulvermuller
2001). Mean values were reported for Wertz 1981 but the standard
deviation (SD) values were unavailable. To facilitate inclusion of
these data within the review, the standard deviation value (13.93)
has been imputed from the Lincoln 1982 Token Test summary
data. The reason for choosing this value was both Wertz 1981 and
Lincoln 1982 used the same form of the Token Test and used it
to measure the language skills of similar participant groups. On
Measures of word fluency were used by Wertz 1981 to compare

participants word finding skills. Mean values for the participants
receiving group SLT and those receiving one-to-one SLT were
reported but no SDs were available and so these data could not be
included in this review.

Participants repetition abilities were compared by Pulvermuller
2001 using the AAT repetition subtest and no evidence of a difference between the groups was found (Analysis 6.4).

22

Wertz 1981 used the Graphic Subtest of the PICA to compare
participants written language skills. Mean values for those participants that received group SLT and those that received one-to-one
SLT were reported but SDs were unavailable. As with the other
PICA data from Wertz 1981, a standard deviation value (21.74)
was identified and imputed from Wertz 1986 where the highest
of three possible values in this trial from relevant clinical groups
was chosen to facilitate inclusion of the study within the review
(Analysis 6.5). There was no evidence of a difference between the
groups.

Three subcomparisons measured the severity of participants aphasia following interventions using the CRRCAE (Jufeng 2005iii),
the PICA (Wertz 1981) and the AAT (Pulvermuller 2001). Summary data from Jufeng 2005iii and Pulvermuller 2001 were available for inclusion within the meta-analysis. Though the mean values for Wertz 1981 trial were available the SD data were missing.
We imputed a SD value (24.64) from Wertz 1986 to facilitate
inclusion of the data within the review. There was no evidence
of a difference between the scores of participants that received
group SLT and those that received one-to-one SLT on this measure
(Analysis 6.6). On follow up at three months the participants that
had received group SLT performed significantly better on the CRRCAE than those that had received one-to-one SLT (P < 0.0001,
MD 33.41, 95% CI 16.76 to 50.06) (Analysis 6.7).

Information on the number of participants leaving during the trials were available for all three subcomparisons (Jufeng 2005iii;
Pulvermuller 2001; Wertz 1981). Two subcomparisons experienced no drop-outs (Jufeng 2005iii; Pulvermuller 2001). In contrast, almost half those randomised in Wertz 1981 failed to remain
in the study (33 drop-outs) but there was no evidence of a difference in the numbers lost to each intervention (Analysis 6.8).

Twenty-two participants were reported to have returned home or
declined to travel to receive the allocated treatment intervention
(see Table 2) but further details on the exact number of participants
declining the interventions or how these numbers are split across
groups was unavailable.
7. Task-specific SLT (SLT A) versus conventional SLT (SLT B)
Eight subcomparisons compared the use of a task-specific approach to SLT with a more generalist conventional SLT approach
(Drummond 1981; Lincoln 1984b; Lincoln 1982i; Lincoln
1982ii; Prins 1989; Pulvermuller 2001; Shewan 1984i; van

Steenbrugge 1981). The range of task-specific SLT A interventions included AMERIND signs used as cues for word-finding
impairment (Drummond 1981); operant training (Lincoln 1982i;
Lincoln 1982ii); operant training with programmed instruction
(Lincoln 1984b); Systematic Therapy for Auditory Comprehension Disorders in Aphasic Patients (STACDAP) (Prins 1989); constraint-induced therapy (Pulvermuller 2001); language-oriented
SLT (Shewan 1984i) and SLT for naming and constructing sentences (van Steenbrugge 1981).
Within this comparison we have included data from Lincoln
1982i, Lincoln 1982ii and Lincoln 1984b, which has been extracted from two cross-over trials (described earlier).
Lincoln 1982i and Lincoln 1982ii randomised participants across
four groups that compared SLT including an operant training
adjunct to SLT with a social support and stimulation adjunct. The
social support and stimulation component acted as a placebo for
the operant training adjunct in the comparison groups. In both
of these subcomparisons the means and SD have been extracted
from the unpublished individual patient data and is inclusive of
the treatment cross-over period. Given the complementary nature
of the cross-over intervention (SLT plus operant training) or (SLT
plus social support) and the clinically relevant nature of the crossover treatments we felt it was appropriate to include these data
within this section of the review. As recommended, we have also
analysed and presented the cross-over inclusive data from these
subcomparisons in separate meta-analyses for readers information
(Analysis 8.1; Analysis 8.2; Analysis 8.3; Analysis 8.4; Analysis
8.5).
All eight subcomparisons evaluating the impact of these specialised
SLT interventions did so by comparing them with conventional
SLT. However, in Lincoln 1984b the conventional SLT group also
had a non-verbal tasks (matching, copying and recall of designs
plus manual dexterity tasks) which acted as a control for the specialist intervention. Similarly, in Lincoln 1982i and Lincoln 1982ii
the participants in the conventional SLT group also had access to
additional structured social stimulation in the form of topic-led
conversations with the therapist.
A range of outcome measures were used by these subcomparisons:
(a) functional communication, (b) receptive language, (c) expressive language, (d) severity of impairment, (e) number of drop-outs
and (f ) compliance with allocated intervention.

Two subcomparisons reported functional communication skills
of participants as measured on the Functional Expression Scale
(Prins 1989; van Steenbrugge 1981). Pulvermuller 2001 measured
functional skills using the Communication Activity Log but these
data were unavailable for the review. On pooling the available
data there was no evidence of a difference between the groups
functional communication skills (Analysis 7.1).

23
Receptive language: reading comprehension

One subcomparison measured participants ability to comprehend
written words (Prins 1989). There was no evidence of a difference
Receptive language: auditory comprehension of single words

Six subcomparisons considered participants auditory comprehension skills across a range of comprehension complexities (Lincoln
1984b; Lincoln 1982i; Lincoln 1982ii; Prins 1989; Pulvermuller
2001; Shewan 1984i). Two subcomparisons measured participants ability to understand single words using the Word Naming
BDAE subtest (Lincoln 1984b; Prins 1989), the Body part identification BDAE subtest (Prins 1989) and the Peabody Picture Vocabulary Test (Lincoln 1984b). Following pooling of the results,
where possible, there was no indication of a difference between
the groups that received task-specific SLT interventions and those
that had received conventional SLT (Analysis 7.2).
Receptive language: other auditory comprehension

Two subcomparisons measured participants ability to comprehend sentences using Miscellaneous Commands (Prins 1989) and
the Aphasia Comprehension Test for Sentences (Shewan 1984i).
Appropriate statistical data from Shewan 1984i were unavailable
and so could not be included in the meta-analysis. There was no
evidence of a difference between the groups sentence comprehension abilities (Analysis 7.3). Prins 1989 measured participants
comprehension skills across levels of complexity on the AmAT
Comprehension Subtest. There was no evidence of a difference between the groups comprehension skills on this measure (Analysis
7.3). Participants auditory comprehension skills on the AAT subtest were tested by Pulvermuller 2001 and there was no evidence
of a difference between the groups performance on this measure (Analysis 7.2). Five subcomparisons evaluated comprehension skills using the Token Test (Lincoln 1982i; Lincoln 1982ii;
Lincoln 1984b; Prins 1989; Pulvermuller 2001). On pooling of
the available data there was no evidence of a difference between
the groups comprehension skills (Analysis 7.3).

Three subcomparisons measured gestural skills on the PICA
subtests which incorporates measures of not just gesture abilities
but also subtests of auditory comprehension and reading abilities
(Lincoln 1982i; Lincoln 1982ii; Lincoln 1984b). Following pooling of these data there was no evidence of a difference in the gestural skills of participants that received SLT with operant training
and those that received SLT with a placebo adjunct (Analysis 7.6).
Participants expressive language skills were considered by seven
subcomparisons (Drummond 1981; Lincoln 1982i; Lincoln
1982ii; Lincoln 1984b; Prins 1989; Pulvermuller 2001; van
Steenbrugge 1981) across a range of levels of complexity from object naming to sentence construction tasks.
Expressive language: spoken naming

Six subcomparisons asked participants to name a variety of nouns
using the Object Naming Test (Lincoln 1982i; Lincoln 1982ii),
the AmAT Naming Test (Prins 1989; van Steenbrugge 1981), 20
items from the Taylor Aphasia Therapy Kit (Drummond 1981)
and the AAT Naming Subtest (Pulvermuller 2001). We were unable to obtain suitable summary data from Drummond 1981 to
permit inclusion within the meta-analysis. There was no evidence
of a difference between the groups naming skills. Nor was there
any evidence of a naming difference between the groups in the
van Steenbrugge 1981 subcomparison at three-week follow up
(Analysis 7.7).
Expressive language: spoken sentence construction

Receptive language: auditory comprehension (treated items)
One subcomparison also reported separate results for components of word and sentence comprehension that had been targeted
within the STADCAP SLT treatment intervention. Participants
ability to comprehend three tests of word or sentence comprehension that depended on phoneme recognition, lexicon and morphological skills (Prins 1989) were measured and compared. There
was no evidence of a difference between the groups given taskspecific SLT or conventional SLT (Analysis 7.4).
Prins 1989 and van Steenbrugge 1981 also compared participants

ability to construct sentences but there was no evidence of a difference between the groups nor was any indication of a difference between the groups at three-week follow up (van Steenbrugge 1981)
(Analysis 7.8).
Expressive language: other spoken tasks

Lincoln 1982i and Lincoln 1982ii compared participants expressive language skills using word fluency tasks and on pooling found

24
those that received conventional SLT performed better than those

that had received task-specific SLT (P = 0.02, SMD -1.05, 95% CI
-1.93 to -0.17). The two subcomparisons also asked participants
to describe a picture and compared their abilities on this expressive
language task but there was no evidence of a difference between
the groups. The PICA Verbal Subtest was used by three subcomparisons to compare participants that received task-specific SLT
and conventional SLT but on pooling there was no evidence of
a difference between the groups (Lincoln 1982i; Lincoln 1982ii;
Lincoln 1984b) (Analysis 7.9).
Expressive language: spoken (treated items)

Participants expressive language skills on items that had been
treated within the specialist Naming and Sentence Construction
SLT intervention were compared to participants expressive abilities on these items following conventional SLT (van Steenbrugge
1981). There was some trend towards better naming of treated
items (P = 0.06) from those participants that had received conventional SLT as compared with those who had received task-specific
SLT, with a similar trend observed at three-week follow up. There
was no evidence of a difference between the groups sentence construction skills (Analysis 7.10).

Pulvermuller 2001 was the only subcomparison to compare participants repetition skills following constraint-induced therapy or
conventional SLT interventions and there was no evidence of a
difference between the groups (Analysis 7.11).
that received a task-specific SLT intervention that included operant training (P = 0.05, MD -0.74, 95% CI -1.50 to 0.01) (Analysis
8.5). There was no evidence of a difference between the groups on
the AAT measure (Pulvermuller 2001) (Analysis 7.13).
Only three subcomparisons reported a loss of participants from
their trials (Lincoln 1982i; Lincoln 1982ii; Shewan 1984i). No
participants were lost from the other five subcomparisons. Thirteen participants were lost across the four groups in Lincoln 1982i
and Lincoln 1982ii but it is unclear to which groups these participants had been randomised. In contrast, Shewan 1984i reported
that six participants dropped out from the language-orientated
SLT intervention while only one dropped out of the conventional
SLT group. There was no significant difference between the numbers of participants lost to each intervention (Analysis 7.14).
As described above, only one subcomparison provided details of
the participants that dropped out of their trial (Shewan 1984i) with
only two deciding to withdraw from the language-orientated SLT
intervention. None voluntarily withdrew from the conventional
SLT group.
8. Operant training SLT (SLT A) versus conventional SLT

(SLTB)
The subcomparisons taken from the cross-over trials are presented

separately within the data and analysis table for information purposes.
9. Semantic SLT (SLT A) versus phonological SLT (SLTB)
Doesborgh 2004a randomised 58 participants to receive either semantic SLT or phonological SLT. The semantic SLT approach focused on improving semantic processing by employing semantic
decision tasks at word, sentence and text level while the phonological SLT approach focused on sound structure by targeting phonological input and output. Between group comparisons were made
on the basis of (a) functional communication, (b) receptive language, (c) expressive language, (d) number of drop-outs and (e)
compliance with allocated intervention. The psychosocial impact,
severity of impairment and economic outcomes were not measured.
Participants overall severity of aphasia impairment was considered

by five subcomparisons using the PICA (Lincoln 1982i; Lincoln
1982ii; Lincoln 1984b), the AAT (Pulvermuller 2001) and the
WAB (Shewan 1984i). Suitable data from Shewan 1984i were unavailable and so could not be included in this meta-analysis. Following pooling of the PICA data, conventional SLT participants
were found to experience significantly less impairment than those
Doesborgh 2004a used the ANELT-A to compare groups that

received semantic SLT to those that received phonological SLT.
There was no evidence of a difference between the two groups
functional communication skills (Analysis 9.1).
Three subcomparisons measured participants written language

expressive skills on the PICA Graphic subtest (Lincoln 1982i;
Lincoln 1982ii; Lincoln 1984b). On pooling, those participants
that had received conventional SLT were found to have significantly better written expressive language skills that those that had
received task-specific SLT (P = 0.05, MD -0.85, 95% CI -1.69 to
-0.1) (Analysis 7.12).

25
not report group comparisons on the basis of functional communication, expressive language, severity of impairment or economic
outcome measures. No participants withdrew from the study so
comparison based on the number of drop-outs was not possible.

Participants auditory comprehension skills were measured by
Doesborgh 2004a using the Semantic Association Test and the
Auditory Lexical Decision Subtests of the PALPA. Using changefrom-baseline values there was no evidence of a difference between
the groups on the Semantic Association Test but the group that
received the phonological SLT performed significantly better on
the Auditory Lexical Decision Subtest than those that received
semantic SLT (P = 0.01, MD -3.50, 95% CI -6.23 to -0.77)
(Analysis 9.2).
(a) Receptive language
Receptive language: auditory

The participants word comprehension skills were measured using
a vocabulary test constructed by Di Carlo 1980. There was no
evidence of a difference between the groups (Analysis 10.1).
Receptive language: reading
Receptive language: reading
Doesborgh 2004a also measured the two groups synonym judgements using a subtest of the PALPA. This test required both synonym judgement and reading comprehension abilities. There was
Di Carlo 1980 compared the two groups reading comprehension

skills using the Reading Recognition and Reading Comprehension
Test. There was no evidence of a difference between the groups on
either of these measures (Analysis 10.2).
(c) Expressive language: repetition
Summary of results
The only measure of expressive skill used by Doesborgh 2004a

was that of the PALPA non-word repetition subtest. There was
no evidence of a difference between the two groups (Analysis 9.4).
(d) Number of drop-outs
Doesborgh 2004a reported the loss from follow up of a total of
12 participants. Equal numbers were lost from both the semantic
SLT and the phonological SLT groups (Analysis 9.5).
(e) Compliance with allocated intervention
Reasons for the loss of 12 participants from the treatment phase
were given by Doesborgh 2004a. Within the semantic SLT group
four participants received less than 40 hours of the planned treatment intervention while in the phonological SLT group two participants received less than 40 hours of treatment and two participants declined to complete the final assessment.
10. Programmed instruction (SLT A) versus nonprogramme instruction (SLTB)
One subcomparison (Di Carlo 1980) investigated the effectiveness of a filmed programmed instruction intervention compared
to non-programmed activity, described by the trialists as viewing
slides and bibliotherapy. Both groups had received conventional
SLT and continued to do so throughout the trial. Di Carlo 1980
compared the groups on measures of receptive language. They did
1. SLT versus no SLT (14 subcomparisons)
Functional communication: eight subcomparisons (data

from five); four measures; no evidence of a difference.
Receptive language: five subcomparisons (data from five);
seven measures; PICA gestural subtest favours SLT P = 0.02, no
other evidence of a difference.
Expressive language: five subcomparisons (data from five);
seven measures; no evidence of a difference.
Severity of impairment: 10 subcomparisons (data from six);
four measures; no evidence of a difference.
Psychosocial impact: four subcomparisons (data from one);
six measures; no evidence of a difference.
Drop-outs: 14 subcomparisons (data from 14); no evidence
of a difference.
Compliance: 11 subcomparisons (data from two); no
evidence of a difference.
Economic outcomes: one subcomparison (no data).
2. SLT versus social support and stimulation (six
subcomparisons)
Functional communication: two subcomparisons (data from

one); three measures; no evidence of a difference.
Receptive language: four subcomparisons (data from two);
five measures; PICA subtest favours social support and
stimulation group (P = 0.04); no other evidence of a difference.

26
Expressive language: three subcomparisons (data from two);

six measures; Object Naming Test and Word Fluency favours
social support and stimulation group (P = 0.003 and P <
0.0001); Caplan and Hanna Sentence Production Test (treated
items) favours SLT (P = 0.01); PICA Verbal and Graphic subtests
favour social support and stimulation group (P = 0.0007; P =
0.01).
Severity: four subcomparisons (data from one); two
measures; PICA favours social support and stimulation group (P
= 0.005).
Psychosocial impact: one subcomparison (no data).
Drop-outs: five subcomparisons (data from four); no
Compliance: four subcomparisons (data from four); no
Economic outcomes: not measured.
3. SLT A versus SLT B (21 subcomparisons)
Functional SLT versus conventional SLT (one

subcomparison)
Functional communication: one subcomparison (data from
one); six measures; CADL change-from-baseline favours
conventional SLT (P = 0.001); Telephone Ordering Task (with
and without concurrent task) favours functional SLT (P =
0.0001 and P = 0.03).
Receptive language: not measured.
Expressive language: one subcomparison (data from one);
two measures; no evidence of a difference.
Severity of impairment: not measured.
Psychosocial impact: not measured.
Drop-outs: one subcomparison (data from one); no dropouts.
Compliance: not applicable.
Intensive versus conventional SLT (four subcomparisons)
Functional communication: not measured.
Receptive language: one subcomparison (data from one); two
measures; AAT Comprehension subtest approaching
significance, favouring intensive SLT (P = 0.06); no other
three measures; AAT written subtest favours intensive SLT (P =
0.01); no other evidence of a difference.
Severity of impairment: four subcomparisons (data from
three); three measures; no evidence of a difference; AAT profile
change from baseline scores suggesting a trend towards favouring
intensive SLT (P = 0.08).
Psychosocial impact: one subcomparison (no data).
Drop-outs: four subcomparisons (data from two); favours

conventional SLT (P = 0.05).
Compliance: two subcomparisons (data from one); no
Volunteer-facilitated SLT versus professional SLT (four

subcomparisons)
one); two measures; no evidence of a difference.
Receptive language: three subcomparisons (data from two);
Expressive language: two subcomparisons (data from two);
five measures; AAT Repetition subtest favoured volunteerfacilitated SLT (P = 0.05); no other evidence of a difference.
Severity of impairment: four subcomparisons (data from
three); three measures; no evidence of a difference.
Drop-outs: four subcomparisons (data from four); no
Compliance: three subcomparisons (data from two); no
Group SLT versus conventional SLT (three subcomparisons)

Functional communication: two subcomparisons (no data);
three measures.
Receptive language: two subcomparisons (data from two);
three measures; no evidence of a difference.
Expressive language: two subcomparisons (data from two);
five measures; no evidence of a difference.
Severity of impairment: three subcomparisons (data from
three); three measures; CRRCAE favoured group SLT at threemonth follow up (P < 0.0001); no other evidence of a difference.
Drop-outs: three subcomparisons (data from three); no
Compliance: one subcomparison (no data).
Task-specific SLT versus conventional SLT (eight

subcomparisons)
Functional communication: three subcomparisons (data
from two); two measures; no evidence of a difference.
Receptive language: six subcomparisons (data from five); 12
measures; no evidence of a difference.
Expressive language: seven subcomparisons (data from six);
12 measures; word fluency and written language favoured
conventional SLT (P = 0.02 and P = 0.05); naming (treated

27
items) and at three-week follow up there was a trend towards

favouring task-specific SLT (P = 0.06).
Severity of impairment: five subcomparisons (data from
four); three measures; PICA favours conventional SLT (P = 0.05).
Drop-outs: eight subcomparisons (data from six); no
Compliance: one subcomparison (data from one); no
Operant training versus conventional SLT (three
subcomparisons)
Functional communication: not measured
Receptive language: three subcomparisons (data from three);
Expressive language: three subcomparisons (data from three);
five measures; word fluency and PICA Graphic subtest favoured
conventional SLT (P = 0.02 and P = 0.05); no other evidence of
a difference.
Severity of impairment: three subcomparisons (data from
three); one measure; PICA overall favoured conventional SLT (P
= 0.05).
Drop-outs: two subcomparisons (no data).
Compliance: two subcomparisons (no data).
Semantic SLT versus phonological SLT (one subcomparison)
one); one measure; no evidence of a difference.
Receptive language: one subcomparison (data from one);
three measures; Auditory Lexical Decision favoured phonological
SLT (P = 0.01); no other evidence of a difference.
one measure; no evidence of a difference.
Drop-outs: one subcomparison (data from one); no evidence
of a difference.
Compliance: one subcomparison (data from one); no
Programmed instruction versus non-programmed
instruction (one subcomparison)
Functional communication: not measured.
Receptive language: one subcomparison (data from one);
three measures; no evidence of a difference.
Expressive language: not measured.

Drop-outs: not measured.
Compliance: not measured.
DISCUSSION
We updated this complex review of the effectiveness of speech and
language therapy interventions for people with aphasia following
stroke to reflect new evidence and developments in clinical practice. We assessed whether (1) SLT is more effective than no SLT,
(2) SLT is more effective than social support and stimulation and
(3) one SLT intervention is more effective than another. The data
from 20 additional trials were identified, synthesised and presented
together with data from 10 trials included in the original review.
Summary of main results

A total of 1840 participants were randomised across 41 subcomparisons. Fourteen compared participants who received SLT with
those who did not. Significant differences between the groups
scores were few but there was some indication of a consistency in
the direction of the results which favoured the provision of SLT.
More data are required to further inform this comparison.
Six subcomparisons compared groups who received SLT with
groups who received social support and stimulation. Most of the
data derived from one small trial prior to cross-over which provided some evidence of a difference in receptive and expressive
language skills and severity which favoured the social support and
stimulation group. This finding is heavily reliant on the data from
a single trial and additional data are required to confirm whether
social support and stimulation provides benefits to some aspects of
participants language skills and on measures of severity of aphasia
impairment.
Twenty-one subcomparisons compared two different types of SLT.
In general, comparisons were based on a small number of subcomparisons involving few participants. Based on the findings of
one trial, functional SLT was found to improve functional tasks
but in more general measures of communicative activities of daily
living the conventional SLT approach was better. Additional data
are required to further inform the comparison.
Intensive SLT was compared to conventional SLT by four subcomparisons and the intensive approach was found to result in benefits in participants written language skills with some indications
of improvements in their receptive language and severity of impairment measures as compared to a conventional SLT approach.
However, the number of participants dropping out from the intensive SLT groups was significantly higher than the conventional

28
SLT group suggesting that such an intensive approach to therapy

is not suited to all patients.
Volunteer-facilitated SLT did not seem to differ remarkably from
professional SLT. This is unsurprising as the volunteers providing
the SLT interventions were trained by the professional therapists,
had been given access to the relevant therapy materials and the
plan for therapeutic interventions was developed by (or under
the direction of ) the professional therapist. The only betweengroup difference identified in this comparison (derived from a
single trial) indicated that the volunteer-facilitated group scored
better on measures of spoken repetition than the conventional SLT
group.
There were very limited data and little evidence of any difference
between group SLT and one-to-one SLT.
Comparisons of task-specific SLT approaches to the provision of
generalist conventional SLT approaches found little evidence of a
between-group difference. Only on the PICA measure of severity
of impairment were the groups found to differ, favouring the conventional SLT approach rather than an operant training SLT approach. This was further supported on closer examination of the
operant training SLT in comparison to conventional SLT when,
in addition to less severity, the conventional SLT groups were also
found to have significantly better scores on measures of word fluency and writing than the operant training SLT groups. While
task-specific approaches may provide more benefits in the retrieval
of language items targeted in therapy than conventional SLT approaches, this raises the question of how functionally relevant such
improvements are.
Overall completeness and applicability of

evidence
We identified a great number of trials (and subcomparisons) of
relevance to our review question with most eligible for inclusion
within the review. However, across the trials included in the review there was a lack of comprehensive data collection, a wide
range of outcome tools employed and disappointingly inadequate
reporting of outcome measures. Within the review, approximately
half of the subcomparisons described measuring receptive (N =
23) and expressive language skills (N = 23) with only two-thirds
reporting suitable data in published format, which permitted inclusion within this review. Thanks to several trialists contributions of unpublished data we were able to fully include approximately 70% to 80% of the receptive measures (N = 19) and expressive measures (N = 21) within the review. The severity of participants aphasia impairment was evaluated by 30 subcomparisons
but unfortunately we were only able to included suitable data from
20 subcomparisons. Similarly, while one subcomparison reported
measuring economic outcomes, no data were available. Few subcomparisons measured participants functional and psychosocial
outcomes, measures that are probably most closely aligned to the
patients sense of recovery and return to normal. From the total
of 41 subcomparisons, less than half (N = 17) described measuring changes in functional communication and of these only half
(N = 11) reported data that could be included within the review.
Even fewer measured psychosocial outcomes (N = 5) and only one
reported data suitable for inclusion within the review.
The degree to which the models of conventional SLT employed
within the trials are reflective of therapists current practice should
be carefully considered across individual treatments in terms of
the frequency, duration and the extent of therapeutic intervention. Participants came from across a wide age range and were experiencing a range of aphasia impairments. However, the length
of time since participants stroke raises questions of how clinically relevant some recruitment parameters were to a SLT clinical
population. Only a quarter of the included subcomparisons (N
= 10) recruited participants within the first few weeks following
their stroke (a participant group of high clinical relevance) while
almost half the subcomparisons (N = 18) recruited participants
six months or more (in some cases many years) following their
stroke: a group that are highly unlikely to be seen in a clinical
setting for rehabilitation purposes. Such recruitment procedures
and the involvement of some participants up to 28 years after the
onset of their aphasia is of limited application to either a clinical
or treatment evaluation setting.
Quality of the evidence

This update adds a significant amount of data to the original review
and so, together with newly improved systematic review methodologies, we are in a better position to draw conclusions regarding
the effectiveness of SLT for aphasia following stroke. In this review we have included a total of 30 trials (which consisted of 41
subcomparisons) involving data from 1840 patients. Methods of
random sequence generation and concealment of allocation were
considered adequate in 13 and six subcomparisons respectively.
The randomisation methodology for most of the remaining subcomparisons had been inadequately described and so it was not
possible to judge the quality of randomisation. The lack of description and detail does not necessarily mean inadequate procedures
were in place but rather a lack of reporting of this detail (Soares
2004). The prevalence of good methodology in relation to blinding of outcome assessors may support this interpretation. Blinding of the outcome assessors was much more widely reported with
more than half of the subcomparisons within the review, 23 of
them, describing adequate blinding procedures. Only eight were
considered not to have adequately blinded assessors with 10 providing too little detail to make a judgement regarding the quality
of blinding.
Almost three-quarters of the subcomparisons in this review (N =
30) were published before the CONSORT statement (Consolidated Standards of Reporting Trials) (Altman 2001; Moher 2001).
Disappointingly, of the 11 subcomparisons published in the last
five years (and after the implementation of the CONSORT state-

29
ment) only four reported the method of generating the randomisation sequence and the methods of concealing allocation. This is
however an improvement on the 30 earlier subcomparisons where
the method of random sequence generation and concealment of allocation was only available for one-fifth of subcomparisons. Thus,
there is some indication of improvements in the quality of the trial
methodologies or of their reporting.
Only two trials reported an a priori power size calculation, which
is reflected in the small numbers of randomised participants across
the subcomparisons: three randomised 10 or fewer participants,
22 randomised up to 50 participants, 13 between 50 and 100
participants, and only three subcomparisons randomised over 100
participants. The randomisation of such small numbers of participants reduces the power of the statistical analyses, raises questions
of the reliability of findings and (given the complexity of various
aphasia impairments) will cause difficulties in ensuring the comparability of the groups at baseline. In this review, we found onefifth of the included subcomparisons had groups that significantly
differed at baseline and group comparability was unclear for another fifth.
Despite these reporting and methodological limitations we have
synthesised a large number of trials that address the effectiveness
of SLT for aphasia following stroke across a number of outcome
measures. Across these measures there is some indication of a consistency in the direction of results when looking at SLT versus
no SLT which appears to favour SLT. With at least nine additional trials of relevance to this review currently ongoing or about
to report, the picture based on the current evidence for SLT for
aphasia following stroke will develop further over time. With a
clear consistency in the direction of results to date in many of the
measures we can be hopeful that with the availability of additional
data the evidence will become more conclusive in relation to the
effectiveness of SLT, social support and different approaches to
SLT provision.
Sixteen of the 41 subcomparisons in this review included all randomised participants in their final analyses. The remaining 25 subcomparisons lost participants during the treatment or follow-up
phases but none employed an intention-to-treat analysis. In some
cases large proportions of participants withdrew from some interventions and in some this appeared to be linked to the intervention itself, with significantly more participants withdrawing from
intensive SLT than conventional SLT. There was a similar suggestion (and a consistency in direction) of higher withdrawals from
groups that were receiving social support and stimulation than
SLT interventions but this did not reach significance (P = 0.09).
Unfortunately few trials gave detailed reasons for withdrawals and
so it was not possible to explore these findings further.
Potential biases in the review process

Within this review we refined the original search strategy and conducted a comprehensive search for high quality trials that evalu-
ated the effectiveness of SLT for aphasia following stroke. While

we are confident we have identified most published trials of relevance to the review it is possible, despite our efforts, that we may be
unaware of additional unpublished work. Our search strategy and
study selection criteria were agreed in advance and applied to all
identified trials. Our data extraction processes were completed independently and then compared. Whenever possible we extracted
all relevant data and sought missing data directly from the trialists
for inclusion within the review. We considered it appropriate to
include cross-over data within our review given the nature of the
comparisons, the points at which the data were extracted and, in
some cases, the availability of individual patient data.
This review has been informed by the availability of individual
patient data (N = 305). In three subcomparisons the individual
data were presented within the associated publications, while for
the remaining nine subcomparisons we are very grateful to the
trialists for the unpublished data thus allowing inclusion within
the review. In addition, other trialists generously contributed the
relevant summary values thus permitting (for the first time) the
full inclusion of important trials from this field (Wertz 1986i;
Wertz 1986ii; Wertz 1986iii) within a systematic review. However, there still remain a number of other trials that could not
be fully included. In some cases the outcome measure summary
data were reported in a format that made it unsuitable for full
inclusion within the reviews meta-analyses. For three additional
trials, outcome measure data were not reported at all (nor were
they available from the authors).
Agreements and disagreements with other

studies or reviews
One of the first reviews in this area was Robey 1994 who reviewed
21 published studies (restricted to English language but not to
randomised controlled trials). They identified at least 19 more
studies that they were unable to include because of the manner
in which the data had been reported. They concluded that the
provision of SLT in the acute stages of aphasia following stroke was
twice as effective as natural recovery patterns. Therapy started after
that acute period had less of an impact but was still evident. They
called for better reporting of data and the use of large sample sizes.
This team later updated this review (Robey 1998a), employing the
same methodologies and included 55 studies looking specifically
at the amount and type of SLT intervention and the impact of
the severity and type of aphasia. Again, they concluded that SLT
was effective, particularly SLT in the acute stages following stroke
and if two or more hours of therapy were provided each week.
However, they again did not have access to all the relevant data
and some key trials such as Wertz 1986 were excluded.
Bhogal 2003 reviewed 10 English language publications of controlled trials from a MEDLINE search (1975 to 2002) and associated references. They found that intensive SLT delivered significant treatment effects (when at least nine hours per week were

30
delivered) but that studies that failed to demonstrate a treatment

effect had only provided about two hours of SLT per week. The
total duration of SLT provision was also negatively correlated with
language outcomes. Cherney 2008 also reviewed 10 English language publications (1990 to 2006; 15 electronic databases; not all
RCTs) and found modest evidence for intensive SLT and benefits
of constraint-inducted language therapy.
In contrast, Moss 2006 reviewed 23 single patient reports involving the provision by a therapist on a one-to-one basis of SLT which
targeted spoken output or auditory comprehension in 57 participants identified following a systematic search (1985 to 2003) of
published or indexed work. They concluded that time since stroke
(and aphasia onset) is not linked to the response to SLT though
they indicate (based on their data) that response to SLT may decline eight years after stroke. However, the highly selected nature
of participants in single cases studies means that reviews based on
such a population group are of questionable relevance to a general
clinical population. Individuals (and their carers) within such reports are likely to be highly motivated, educated, dedicated and
reliable participants (Moss 2006).
AUTHORS CONCLUSIONS
Implications for practice
The evidence presented within this review shows some indication
of the effectiveness of SLT for people with aphasia following stroke,
especially in relation to functional communication, expressive language and the severity of aphasia.
We also observed a consistency in the direction of results which
favours intensive SLT over conventional SLT, though significantly
more people withdrew from intensive SLT treatment than conventional SLT.
SLT facilitated by a trained volunteer under the direction of a
therapist appears to be as effective as the provision of SLT from
a professional therapist. This is probably unsurprising as the volunteers receive specialist training, have access to therapy materials
and in many cases are delivering therapy interventions designed
and overseen by a professional therapist. This is a model of treatment often used in therapy in the UK. There was insufficient evidence to draw any conclusions in relation to the effectiveness of
group SLT as compared to conventional one-to-one SLT.
There is some very limited evidence that social support and stimulation may be beneficial to patients receptive and expressive language skills based on a single cross-over trial.
There was insufficient evidence within this review to establish the
effectiveness of one SLT approach over another.
Implications for research

This review presents a synthesis of SLT trial data which shows
some indications of the effectiveness of SLT for people with aphasia following stroke. Results from those additional trials recently
completed and currently ongoing will further contribute to this evidence base. The prevalence of outcome assessor blinding amongst
the trials included in this review is evidence of the quality of research undertaken to date. Future trials in this area should build
upon this by ensuring the use of standardised objective outcome
measures by assessors blinded to the participants background and
intervention. Digitally recording conversational interactions or
test performance for rating by independent assessors is one model
of outcome assessment that should be encouraged.
Some of the limitations of the review findings reflect limitations
in the availability of suitable data for inclusion within the review.
Researchers, funders, reviewers and editors should ensure that the
findings from future trials are fully published. The recommendations of the CONSORT statement (Altman 2001; Moher 2001)
should be adhered to, thus ensuring the quality of the trial is fully
demonstrated. Similarly, trialists should provide full descriptions
of the relevant statistical summary data (means and standard deviations of final value scores) thus allowing inclusion of their data
within relevant meta-analyses.
Future work might consider the more detailed examination of
the effectiveness of SLT as it applies across a range of patients
differing in aphasia profile, the length of time since their stroke
and other factors. It is possible that some SLT approaches may be
more effective for some patient groups (and aphasia profiles) than
others.
We saw some suggestion within the review of the effectiveness
of intensive approaches to SLT when compared to conventional
SLT. We need more data on volunteer-facilitated SLT, group SLT
and functional SLT approaches before we can be confident about
drawing conclusions in relation to their effectiveness. We still need
to establish what is the optimum approach, frequency, duration of
allocation and format of SLT provision for specific patient groups.
Future investigations should also consider contributing to the evidence base as it relates to the effectiveness of a social support and
stimulation intervention in comparison to a SLT intervention.
A priori sample size calculations should be employed thus ensuring SLT trials are adequately powered to demonstrate differences.
The challenge for SLT researchers and clinicians will be to design,
develop, conduct and support larger trials. It is essential for the
success of these trials that the work is undertaken in a collaborative
manner between patients, clinicians and researchers. Standardised
outcome measures should be employed to evaluate the impact of
SLT on participants functional communication, expressive and
receptive language skills and the severity of their aphasia.

31
ACKNOWLEDGEMENTS
We would like to acknowledge Jenny Greener and Renata Whurr,
authors of the original review, and the significant contribution the
original review made to the field.
We would like to thank Hazel Fraser for her comments and suggestions for this review, and for providing us with relevant trials from
the Cochrane Stroke Groups Trials Register and Brenda Thomas
for her help with developing the search strategy.
We thank the Cochrane Stroke Group Editors and all those who
commented on the draft review, in particular Peter Langhorne,
Audrey Bowen, Nadina Lincoln, Cameron Sellars and Catherine
Mackenzie.
We are grateful to the Chinese Cochrane Centre, Mrs Christine
Versluis and Dr Audrey Morrison for translations.
We would like to thank all the trialists who responded to our
queries, provided translations and contributed unpublished data
and additional information to this review.
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35
IHCOP {unpublished data only}

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References to other published versions of this review

Greener 1999
Greener J, Enderby P, Whurr R. Speech and language
therapy for aphasia following stroke. Cochrane Database of
Systematic Reviews 1999, Issue 4. [Art. No.: CD000425.
DOI: 10.1002/14651858.CD000425]
Indicates the major publication for the study

38
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Bakheit 2007
Methods
RCT
Participants
Inclusion criteria: first stroke, below normal on WAB, native English speaker, medically
stable, fit for participation
Exclusion criteria: depression, Parkinsons disease, unlikely to survive, severe dysarthria,
more than 15 miles from hospital
Group 1: 51 participants
Groups comparable at baseline
Interventions
1. Intensive SLT (1 hour therapy 5 times weekly for 12 weeks)

2. Conventional SLT (1 hour therapy 2 sessions weekly for 12 weeks)
Intensive SLT and conventional SLT: tasks included picture-object selection, object naming, recognition and associations; expression of feelings and opinions; improving conversational skills; gestural and non-verbal communication (including communication aids
and equipment)
Outcomes
Western Aphasia Battery

Assessed at baseline and weeks 4, 8, 12 and 24
Notes
UK
A further NHS Group was not randomised (first 6 consecutive participants allocated
to this group) and were therefore excluded from this review
Drop-outs: 31 participants (Intensive 20; Conventional 11)
Risk of bias
Item
Authors judgement
Description
Adequate sequence generation?
Yes
Random numbers table
Allocation concealment?
Yes
Sequentially numbered sealed envelopes
Blinding?
All outcomes
Yes
Outcome assessors blinded
Incomplete outcome data addressed?

All outcomes
No
ITT analysis not used
Free of selective reporting?
Yes
Statistical data included in the review
Free of other bias?
Unclear
Sample size calculation not reported

Only 13/51 participants in intensive SLT group received 80%
or more of prescribed treatment

39
David 1982
Methods
Parallel group RCT
Participants
Inclusion criteria: aphasia, less than 85% on Functional Communication Profile (x 2),
English speaking, at least 3 weeks after stroke
Exclusion criteria: previous SLT, deafness, blindness or confusion preventing participation
Baseline between group difference: the conventional SLT group were older
Interventions
1. Conventional SLT (30 hours therapy for up to 20 weeks)

2. Social support and stimulation (30 hours contact for up to 20 weeks)
Conventional SLT: therapist directed SLT
Social support and stimulation: untrained volunteers received details about participants
aphasia, general support and within-treatment assessment scores. They were not given
instruction in SLT techniques
Outcomes
Functional Communication Profile, Schuell Assessment

Assessed twice at baseline and at 2, 4, 8, 12 weeks and post-treatment (3 and 6-month
follow ups)
Notes
UK
Randomisation details provided through personal communication with authors of original review
Drop-outs: 82 participants (conventional SLT 34; social support 48)
Risk of bias
Item
Authors judgement
Description
Yes
Yes
Adequate
Blinding?
All outcomes
Yes
Outcome assessor not treating therapist

All outcomes
No
ITT analysis was not used
Unclear
Free of other bias?
Unclear

Participants in the social support and stimulation group were
younger (mean age 65 years; SD 10.6) than those in the conventional SLT group (mean age 70 years; SD 8.7)

40
Denes 1996
Methods
Parallel group RCT
Participants
Inclusion criteria: global aphasia, left CVA, within first year after stroke, right-handed,
native Italian speakers, literate
Exclusion criteria: none listed
Interventions
1. Intensive SLT (45 to 60-minute session approximately 5 times weekly for 6 months)
2. Conventional SLT (45 to 60-minute session approximately 3 times weekly for 6
months)
Intensive SLT: conversational approach more focus on comprehension (e.g. picturematching to understanding complex scenes, short stories, engaging patient in conversation, retelling personally relevant stories)
Conventional SLT: based on stimulation approach
Outcomes
Aachen Aphasia Test

Assessed at baseline and 6 months
Notes
Italy
Data from an additional 4 non-randomised participants with global aphasia were also
reported. They received no SLT intervention but were assessed at 6-monthly intervals
and their scores were used to account for spontaneous recovery. They were not included
in this review
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Yes

All outcomes
Yes
All randomised participants included in analysis
Yes
Free of other bias?
Unclear


41
Di Carlo 1980
Methods
Parallel group RCT
Participants
Inclusion criteria: right-handed, left MCA stroke

Interventions
1. Conventional SLT with filmed programmed instruction (programme lasted at least

80 hours for between 5 to 22 months)
2. Conventional SLT with non-programmed activity (lasted at least 80 hours for between
6 to 9 months)
Filmed programmed instruction: perceptual, thinking and language training films (designed for population with hearing impairment) based on linguistic learning theory;
passing criterion of 80%, then progression to the next film
Non-programme activity: viewing slides, bibliotherapy
Outcomes
Reading recognition, reading comprehension, visual closure, visual learning, vocabulary

learning
Assessed at baseline, mid-test and at end of treatment
Notes
USA
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Unclear
Outcome assessor blinding not described

All outcomes
Yes
Yes
Individual patient data reported across all measures
Free of other bias?
Unclear


42
Doesborgh 2004a
Methods
Parallel group RCT
Participants
Inclusion criteria: > 3 months after stroke, experiencing both semantic and phonological
deficits, moderate/severe aphasia
Exclusion criteria: illiterate, non-native speaker, dysarthria, global aphasia, developmental/severe acquired dyslexia, visual perceptual deficit, recovered/no aphasia
Group 1 older than Group 2
Interventions
1. Semantic treatment SLT (1.5 to 3 hours in 2 to 3 sessions weekly for up to 40 weeks)

2. Phonological treatment SLT (1.5 to 3 hours in 2 to 3 sessions weekly for up to 40
weeks)
Semantic treatment SLT: aimed to enhance semantic processing (multiple choice, right/
wrong format), several levels of difficulty
Phonological treatment SLT: sound structure targeting phonological input and output
routes, e.g. rhyming consonant clusters, stress patterns, compiling words, syllabification,
phonetic similarity
Outcomes
Amsterdam Nijmegen Everyday Language Test Scale A (ANELT-A), Semantic Association Test (SAT), PALPA synonym judgement, PALPA repetition of non-words, PALPA
auditory lexical decision
Assessed at baseline and end of treatment
Notes
The Netherlands
Co-morbidity: memory and executive function impairment
Drop-outs: 12 participants (semantic SLT 6; phonological SLT 6)
A priori sample size calculated
Risk of bias
Item
Authors judgement
Description
Yes
Computer-generated
Yes
Blinding?
All outcomes
Yes

All outcomes
No
Trialists reported ITT

3 participants not included (ANELT scores missing)
On-treatment analysis used
Yes
Free of other bias?
No
Semantic SLT group older than phonological SLT group


43
Doesborgh 2004b
Methods
RCT
Participants
Inclusion criteria: age 20 to 86 years, native Dutch speaker, minimum 11 months after
stroke with moderate to severe naming deficits
Exclusion criteria: illiterate, global or rest aphasia, developmental dyslexia
Groups similar at baseline
Interventions
1. Computer-mediated SLT (30 to 45 minutes 2 to 3 sessions weekly for 2 months)

2. No SLT (6 to 8 weeks)
Computer-mediated SLT: improve naming using computer cueing programme
Outcomes

Boston Naming Test, ANELT-A
Notes
The Netherlands
Co-intervention: psychosocial group therapy aimed at coping with consequences of
aphasia, unclear if all participated
Patient confounder: executive function deficits
Drop-outs: 1 participant (computer-mediated SLT 1; no SLT 0)
Risk of bias
Item
Authors judgement
Description
Yes
Computer-generated sequence
Yes
Concealment in sequentially numbered opaque sealed envelopes
Blinding?
All outcomes
No
Trialists were the outcome assessors

All outcomes
No
Yes
Free of other bias?
Yes


44
Drummond 1981
Methods
Parallel group RCT
Participants
Inclusion criteria: none listed

Interventions
1. Gesture Cueing SLT: 15 to 30 minutes daily for 2 weeks

2. Conventional SLT: 15 to 30 minutes daily for 2 weeks
Gestural cueing (AMERIND): signs to facilitate word finding
Conventional SLT: initial syllable and sentence completion cues to facilitate word finding
Outcomes
Picture naming test (20/30 items from the Aphasia Therapy Kit Taylor 1959), response
times
Assessed at baseline and at end of treatment
Notes
USA
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Unclear

All outcomes
Yes
Unclear
Suitable statistical data permitting inclusion within the review

unavailable
Free of other bias?
Unclear
Inclusion criteria not listed

Elman 1999
Methods
Cross-over group RCT (only data collected prior to cross-over treatment included in this
review)
Participants
Inclusion criteria: > 6 months after stroke, completed SLT available via insurance, single
left hemisphere stroke, 80 years or younger, premorbidly literate in English, no medical
complications or history of alcoholism, 10th to 90th overall percentile on SPICA on
entry, attend more than 80% of therapy

45
Elman 1999
(Continued)
Exclusion criteria: multiple brain lesions, diagnosed alcoholism

Groups comparable at baseline (age, education level, aphasia severity)
Interventions
1. Conventional SLT: 2.5 hour session twice weekly for 4 months

2. Social support and stimulation: at least 3 hours weekly for 4 months)
Conventional SLT: improve ability to convey message using any verbal/non-verbal methods in group format, social breaks for communication practice, performance artist (1
hour weekly) to facilitate physical exercises, creative expression
Social support and stimulation: participants attended social group activities of their
choice, e.g. church groups
Outcomes
Shortened Porch Index of Communicative Ability, Western Aphasia Battery AQ, Communicative Activities in Daily Living
Assessed at baseline, 2 and 4 months and 4 to 6 weeks from end of treatment
Notes
USA
Drop-outs: 7 participants (conventional SLT 3; social support and stimulation 4)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
No
Outcome assessor inadequately blinded

All outcomes
No
Unclear
Statistical data reported unsuitable for inclusion within the review
Free of other bias?
Unclear
Groups comparable at baseline (age, education level, aphasia severity)

Hinckley 2001
Methods
Parallel group RCT
Participants
Inclusion criteria: single left hemisphere stroke, native English speaker, minimum 3
months after stroke, hearing and vision corrected to normal, minimum high school
education, chronic non-fluent aphasia

46
Hinckley 2001
(Continued)

Groups comparable at baseline (age, time post-onset, aphasia severity, education, occupation)
Interventions
1. Functional SLT: 20 hours weekly for 5 weeks

2. Conventional SLT: 20 hours weekly for 5 weeks
Functional SLT: disability based, context trained, role plays of functional tasks, establish compensatory strategies (practise ordering by telephone, self-generate individualised
strategies)
Conventional SLT: impairment based, skill trained, aimed at remediating deficit areas
using cueing hierarchies
Outcomes
CADL-2, CETI (completed by primary carer), phone and written functional task developed for project (catalogue ordering quiet and tone), PALPA oral and written picture
naming
Notes
USA
5 additional participants were non-randomly assigned to a baseline group (both functional SLT and conventional SLT) but they were excluded from this review
In the functional SLT group, therapy was discontinued when performance on training
probes (50% trained items) reached a minimum of 90% accuracy for 3 consecutive
sessions
All SLTs were trained in 2 treatment approaches
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Unclear
Outcome assessor not reported

All outcomes
Yes
All randomised participants included in analyses
Yes
Statistical data included within the review
Free of other bias?
Unclear
Groups comparable at baseline (age, time post-onset, aphasia

severity, education, occupation)

47
Jufeng 2005i
Methods
Parallel group RCT
Participants
Inclusion criteria: post-stroke aphasia

Comparability of groups at baseline unclear
Interventions
1. Group SLT: daily for 28 days

2. No SLT
Group SLT: participants talk with a doctor/nurse in small groups (10 participants)
Participants encouraged to communicate with each other
Outcomes
Chinese Rehabilitation Research Centre Aphasia Examination (CRRCAE)

Assessed at baseline, 28 days and 3-month follow up
Notes
China
Translated by Chinese Cochrane Centre
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Yes
Outcome assessor blinded

All outcomes
Yes
Yes
Free of other bias?
Unclear

Limited inclusion criteria listed and no exclusion criteria
Jufeng 2005ii
Methods
Parallel group RCT
Participants
Inclusion criteria: post-stroke aphasia


48
Jufeng 2005ii
(Continued)
Interventions
1. Conventional SLT: daily for 28 days

2. No SLT
Conventional SLT: 1-to-1 rehabilitative training, i.e. 1 nurse talked with 1 participant
Outcomes

Notes
China
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
B - Unclear
Blinding?
All outcomes
Yes

All outcomes
Yes
Yes
Free of other bias?
Unclear

Jufeng 2005iii
Methods
Parallel group RCT
Participants
Inclusion criteria: aphasia following stroke

Interventions
1. Group SLT: daily for 28 days

2. Conventional SLT: daily for 28 days
Group SLT: participants talk with a doctor/nurse in small groups (10 participants)
Participants encouraged to communicate with each other
Conventional SLT: 1-to-1 rehabilitative training, i.e. 1 nurse talked with 1 participant

49
Jufeng 2005iii
(Continued)
Outcomes

Notes
China
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Yes

All outcomes
Yes
Yes
Free of other bias?
Unclear

Katz 1997i
Methods
Parallel group RCT
Participants
Inclusion criteria: single left hemisphere stroke, maximum 85 years, minimum 1 year
after stroke, PICA overall between 15th to 90th percentile, premorbidly right handed,
minimum education 8th grade, premorbidly literate in English, vision no worse than
20/100 corrected in better eye, hearing no worse than 40 dB unaided in better ear, no
language treatment 3 months before entry to study, non-institutionalised living environment
Exclusion criteria: premorbid psychiatric, reading or writing problems
Groups were comparable at baseline
Interventions
1. Computer-mediated SLT: 3 hours weekly for 26 weeks

2. No SLT
Computer-mediated SLT: computerised language tasks using visual matching and reading comprehension software
No SLT: no computer-based reading intervention or stimulation

50
Katz 1997i
(Continued)
Outcomes
Porch Index of Communicative Ability, Western Aphasia Battery Aphasia Quotient

Assessed at baseline, 13 and 26 weeks
Notes
USA
Drop-outs: 6 participants (computer-mediated SLT 0, no SLT 6)
Across 6 hospitals, 2 community stroke groups across 5 cities
Risk of bias
Item
Authors judgement
Description
Yes
Unclear
B - Unclear
Blinding?
All outcomes
Yes
Outcomes measured by 1 of 4 SLTs, 95% checked by second

SLT with no knowledge of group allocation

All outcomes
No
Yes
Free of other bias?
Unclear

Katz 1997ii
Methods
Parallel group RCT
Participants
Inclusion criteria: single left hemisphere stroke, maximum 85 years, minimum 1 year
after stroke, PICA overall between 15th to 90th percentile, premorbidly right handed,
minimum education 8th grade, premorbidly literate in English, vision no worse than 20/
100 corrected, hearing no worse than 40 dB unaided, no language treatment 3 months
before entry to study, non-institutionalised living environment
Exclusion criteria: premorbid psychiatric, reading or writing problems
Interventions
1. Computer-mediated SLT: 3 hours weekly for 26 weeks

2. Computer-based placebo: 3 hours weekly for 26 weeks
Computer-mediated SLT: computerised language tasks using visual matching and reading comprehension software
Computer-based placebo: computerised cognitive rehabilitation software and arcadestyle games, no language stimulation

51
Katz 1997ii
(Continued)
Outcomes
Porch Index of Communicative Ability, Western Aphasia Battery Aphasia Quotient

Assessed at baseline, 13 and 26 weeks
Notes
USA
Drop-outs: 2 participants (computer-mediated SLT 0; no SLT/computer-based placebo
2)
Across 6 hospitals, 2 community stroke groups across 5 cities
Risk of bias
Item
Authors judgement
Description
Yes
Unclear
B - Unclear
Blinding?
All outcomes
Yes
Outcomes measured by 1 of 4 SLTs, 95% checked by 2nd SLT

with no knowledge of group allocation

All outcomes
No
Yes
Free of other bias?
Unclear

Leal 1993
Methods
Parallel group RCT (stratified by aphasia type)
Participants
Inclusion criteria: no history of neurologic or psychiatric disease, first left stroke (single)
, first month after stroke, moderate-severe aphasia, good health, maximum 70 years,
residing near hospital with flexible transport
Exclusion criteria: mild aphasia (i.e. Aphasia Quotient above 80% on Test Battery for
Aphasia)
Interventions
1. Conventional SLT: 3 sessions weekly for 6 months

2. Volunteer-facilitated SLT: unclear
Conventional SLT: conventional hospital-based SLT rehabilitation programme
Volunteer-facilitated SLT: speech and language therapist provided relatives with information and working material; they were encouraged to stimulate the patient as much as
possible; monitored monthly by therapist

52
Leal 1993
(Continued)
Outcomes
Test Battery for Aphasia created by trialists (reported to have good correlation with
Western Aphasia Battery)
Assessed at baseline and 6 months post stroke
Notes
Portugal
Drop-outs: 34 participants (conventional SLT 21; volunteer-facilitated SLT 13)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Yes
Outcome assessor not therapist

All outcomes
No
Unclear
Statistical data reported in a manner unsuitable for inclusion within the review
Free of other bias?
Unclear
Groups were comparable at baseline. Sample size calculation not reported
Lincoln 1982i
Methods
Cross-over RCT (data extracted after completion of cross-over treatment)
Participants
Inclusion criteria: moderate aphasia after stroke, no previous history of brain damage,
to attend for a minimum of eight weeks, PICA overall between 35th to 65th percentile
Exclusion criteria: severely or mildly aphasic
Interventions
1. Conventional SLT followed by operant training SLT (30-minute session 4 times

weekly for 4 weeks followed by another 4 weeks with cross-over intervention
2. Conventional SLT followed by social support and stimulation (30-minute session 4
times weekly for 4 weeks followed by another 4 weeks with cross-over intervention
Social support and stimulation: pre-determined topics of conversation, participant initiates as able, direct questioning/verbal encouragement given, no attempts to correct
responses
Conventional SLT: automatic and serial speech, picture-word/sentence matching, reading, writing, verbal encouragement
Operant training: verbal conditioning procedure (reinforcement, tokens for correct responses, incorrect responses ignored)

53
Lincoln 1982i
(Continued)
Outcomes
Porch Index of Communicative Ability, Token Test (shortened), object naming test,
word fluency naming tasks, picture description, self-rating abilities
Notes
UK
Some participants unable to complete full number of sessions (leaving slightly early,
insufficient therapist time, holidays occurring during trial)
Drop-outs: 13 participants (group allocation unclear)
Risk of bias
Item
Authors judgement
Description
Yes
No
Partial: participants recruited by speech

and language therapists then assigned to intervention by trialist
Blinding?
All outcomes
Yes

All outcomes
No
Yes
Free of other bias?
Yes

Lincoln 1982ii
Methods
Cross-over RCT (data extracted after completion of cross-over treatment)
Participants
to attend for a minimum of eight weeks, PICA overall between 35th to 65th percentile
Interventions
1. Operant training SLT followed by conventional SLT: 30-minute session 4 times weekly
for 4 weeks followed by another 4 weeks with cross-over intervention
2. Social support and stimulation followed by conventional SLT: 30-minute session 4
times weekly for 4 weeks followed by another 4 weeks with cross-over intervention
Social support and stimulation: pre-determined topics of conversation, participant initiates as able, direct questioning/verbal encouragement given, no attempts to correct
responses
Conventional SLT: automatic and serial speech, picture-word/sentence matching, read-

54
Lincoln 1982ii
(Continued)
ing, writing, verbal encouragement

Operant training: verbal conditioning procedure (reinforcement, tokens for correct responses, incorrect responses ignored)
Outcomes
Notes
UK
Risk of bias
Item
Authors judgement
Description
Yes
No

Blinding?
All outcomes
Yes

All outcomes
Unclear
Yes
Free of other bias?
Unclear

Lincoln 1982iii
Methods
Cross-over RCT (data extracted up to point of cross-over)
Participants
to attend for a minimum of 8 weeks, PICA overall between 35th to 65th percentile
Interventions
1. Conventional SLT: 30-minute session 4 times weekly for 4 weeks (before cross-over)
2. Social support and stimulation: 30-minute session 4 times weekly for 4 weeks (before
cross-over)
Social support and stimulation: pre-determined topics of conversation, participant ini-

55
Lincoln 1982iii
(Continued)
tiates as able, direct questioning/verbal encouragement given, no attempts to correct

responses
Conventional SLT: automatic and serial speech, picture-word/sentence matching, reading, writing, verbal encouragement
Outcomes
Notes
UK
Risk of bias
Item
Authors judgement
Description
Yes
No

Blinding?
All outcomes
Yes

All outcomes
Unclear
Yes
Free of other bias?
Unclear

Lincoln 1984a
Methods
Parallel group RCT
Participants
Inclusion criteria: acute stroke, admitted to Nottingham hospital

Exclusion criteria: unable to tolerate full language testing at 10 weeks, very mild aphasia,
severe dysarthria
Data reported: 191 participants
Groups comparable at baseline (age, gender, aphasia types)

56
Lincoln 1984a
(Continued)
Interventions
1. Conventional SLT: 1-hour session 2 times weekly for 24 weeks

2. No SLT (deferred SLT)
Conventional SLT: as chosen by each SLT
Outcomes
Porch Index of Communicative Ability, Functional Communication Profile

Secondary outcome: Multiple Adjective Affect Checklist
Assessed at baseline, 12 weeks and at end of treatment at 24 weeks
Notes
UK
Method of randomisation and concealed allocation provided through personal communication with authors of original review
Other hospital treatment given as normal
Not all patients received planned number of sessions mainly due to recovery or withdrawal from treatment
Drop-outs: 166 participants (conventional SLT 76; no SLT 90)
Risk of bias
Item
Authors judgement
Description
Yes
Yes
Blinding?
All outcomes
Yes

All outcomes
No
Yes
Free of other bias?
Unclear

Lincoln 1984b
Methods
Cross-over RCT (only data collected prior to cross-over treatment included in this review)
Participants
Inclusion criteria: < 35th percentile of Porch Index of Communicative Ability, severe
aphasia following stroke, spontaneous speech (few single words), writing limited to
copying, poor auditory comprehension, < average non-verbal intellectual functioning

57
Lincoln 1984b
(Continued)
Interventions
1. Programmed instruction with operant training plus conventional SLT: 30 minute

session twice weekly for 4 weeks, followed by cross-over
2. Attention placebo plus conventional SLT: 30-minute session twice weekly for 4 weeks,
followed by cross-over
Programmed instruction with operant training: electric board graded language tasks,
board lights in response to correct answer plus therapist provides verbal praise; for incorrect answers, there is no light response, the therapist shakes head and provides verbal
feedback - no
Attention placebo: non-verbal tasks (matching, copying, recall of designs, performance
scale of WAIS, manual dexterity tasks)
Conventional SLT: as provided by qualified speech and language therapist
Outcomes
Porch Index of Communicative Ability, Token Test, Peabody PCT, object naming test
Assessed at baseline, 4 weeks then 8 weeks following cross-over
Notes
UK
The same therapist provided conventional SLT to both groups
Manner of reporting prevents inclusion of data within the meta-analyses
Comparisons between group 1 and group 2 showed group 2 performed significantly
better on PICA test (reading cards) and copying shapes than group 1
Risk of bias
Item
Authors judgement
Description
Yes
No

Blinding?
All outcomes
Unclear
Outcome assessor blinded for one measure

only (PICA)

All outcomes
Yes
All randomised participants included in

analyses
Yes
Free of other bias?
Unclear


58
Lyon 1997
Methods
Parallel group RCT
Participants
Inclusion criteria (patient): minimum 1 year after stroke, no bilateral brain damage,
ability to ambulate short distances, function independently in primary ADL, English
primary language, normal range of cognition, hearing and vision, weekly contact with
primary caregiver, history free of psychosis
Inclusion criteria (caregiver): normal cognitive, hearing and vision, no history of psychiatric problems
Exclusion criteria: none reported
Group 1: 18 participants (7 triads)
Group 2: 9 participants (3 triads)
Each triad comprised 1 person with aphasia, 1 caregiver, 1 communication partner
Interventions
1. Functional SLT: Phase A: 1 to 1.5 hours twice weekly for 6 weeks; Phase B: 1 to 2hour session (clinic) plus 2 to 4-hour session (community) once weekly for 14 weeks
2. No SLT intervention
Functional SLT: Phase A: clinic-based, establishing effective means of communication
between person with aphasia and communication partner, maximise pairs communication strategies; Phase B: home or community-based, activities chosen by person with
aphasia
Outcomes
Boston Diagnostic Aphasia Examination, Communicative Abilities of Daily Living, Affect Balance Scale, Psychological Wellbeing Index, Communication Readiness and Use
Index, informal subjective measures
Assessed at baseline and post-treatment
Notes
USA
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
No
Outcome assessors inadequately blinded

All outcomes
Unclear
All randomised participants appear to have been included in

analyses but it is unclear
No
Free of other bias?
Unclear
Comparability of groups at baseline unclear. Sample size calculation not reported

59
MacKay 1988
Methods
Parallel group RCT
Participants
Inclusion criteria: minimum age 30 years, post-stroke aphasia, minimum 6 months postonset, living within 50 mile radius of hospital/specified geographical area
96 participants in total: division between groups unclear
Unclear whether groups were comparable at baseline
Interventions
1. Volunteer-facilitated SLT: 3 to 6 hours once weekly for 1 year

2. No SLT
Volunteer-facilitated SLT: language and social stimulation
Outcomes
Communicative Abilities of Daily Living, trialist assessment measuring social/interpersonal skills, structured questionnaires assessing economic, medical and demographic factors (completed by carers/family members)
Assessed at baseline, 6, 12, 18 and 24 months
Notes
USA
Participants continued individual medical/nursing care
Drop-outs: 1 (no SLT group 1)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Yes

All outcomes
No
No
Data reported unsuitable for inclusion within the review
Free of other bias?
Unclear

Meikle 1979
Methods
Parallel group RCT
Participants
Inclusion criteria: aphasia after stroke, minimum 3 weeks after stroke


60
Meikle 1979
(Continued)
Group that received conventional SLT had more weeks in the trial than the volunteerfacilitated SLT group
Interventions
1. Volunteer-facilitated SLT: 4 home visits weekly plus group sessions for a mean of 20.8
(13.5) (range 2 to 46) weeks
2. Conventional SLT: 45-minute session 3 to 5 times weekly plus group sessions for a
mean of 37.13 (21.89) (range 7 to 84) weeks
Volunteer-facilitated SLT: volunteers given basic background to aphasia, standard items
of SLT equipment, initial and ongoing support and advice, encouraged to use initiative
and ingenuity in developing therapeutic techniques
Conventional SLT: chosen by SLT (no details)
Outcomes
Porch Index of Communicative Ability

Assessed at baseline and at 6-week intervals until end of trial
Wolfson Test (unpublished) (comprehension, verbal expression, writing, spelling)
Assessed at baseline, after 3 months and at end of treatment
Notes
UK
In the conventional SLT group 5 participants missed up to half their possible treatments
(illness, holidays, transport difficulties)
Unclear whether volunteer supervisor was a speech and language therapist
Participants remained in trial until 2 successful estimations on PICA showed no appreciable improvement, they requested withdrawal or until end of trial in December 1978
Participants who plateaued exited trial and counted as successes
Drop-outs: 2 (conventional SLT 0; volunteer-facilitated SLT 2)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
No
Outcome assessor not blinded

All outcomes
No
Yes
Free of other bias?
Unclear
Group that received conventional SLT had more weeks in the

trial than the volunteer-facilitated SLT group
In the conventional SLT group 5 participants missed up to half
their possible treatments (illness, holidays, transport difficulties)

61
Meinzer 2007
Methods
Parallel group RCT
Participants
Inclusion criteria: 1 or more participating relative, single left hemisphere stroke, aphasia,
minimum 6 months post-onset, globally aphasic if residual expressive language, i.e. repeat
short phrases
Group 1: 10 participants (4 subgroups)
Group 2: 10 participants (4 subgroups)
Participants receiving constraint-induced SLT were younger than those in the volunteerfacilitated group
Interventions
1. Constraint-induced SLT: 3 hours daily for 10 consecutive working days

2. Volunteer-facilitated constraint-induced SLT: 3 hours daily for 10 consecutive working
days
Constraint-induced SLT: communicative language games, pairs of cards depicting objects, everyday situations or words; screens between the participants prevents seeing each
others cards; participant must choose a card from their own set and ask for the identical card from another participant; can be adjusted to target different levels of language
complexity
Volunteer-facilitated constraint-induced SLT: relatives volunteered to receive 2-hour introduction to constraint-induced SLT; they were supervised during first 2 of 10 sessions
by experienced therapist; following 8 sessions experts were available, further group training sessions at end of each daily training session; where 2 or more relatives were available
they alternated each day
Outcomes
Aachen Aphasia Test (Token Test, repetition, written language, naming, comprehension)
Assessed at baseline and immediately post-treatment
Notes
Germany
One participant in each group had mild apraxia of speech
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Yes

All outcomes
Yes
Yes

62
Meinzer 2007
(Continued)
Free of other bias?
Unclear
Participants receiving constraint-induced SLT were younger

than those in the trained volunteers group
ORLA 2006
Methods
RCT
Participants
Inclusion criteria: right-handed, non-fluent aphasia, single left ischaemic stroke at least
6 months post-onset
Groups seem to be comparable
Interventions
1. Intensive SLT: 10 hours weekly for 6 weeks

2. Conventional SLT: 4 hours weekly for 6 weeks
In both interventions patients used a computer programme which allows patient to
practise reading sentences aloud together with a virtual therapist
A non-randomised third group that acted as a control group was also included in the
study report but was excluded from this review
Outcomes
Western Aphasia Battery Aphasia Quotient
Notes
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Unclear

All outcomes
Yes
Yes
Free of other bias?
Unclear
Groups seem to be comparable at baseline


63
Prins 1989
Methods
Parallel group RCT
Participants
Inclusion criteria: unilateral left CVA, minimum 3 months post-onset, < 80% on auditory
comprehension test, good prognosis for auditory comprehension per SLT, motivated and
fit for participation
Interventions
1. STACDAP SLT: 2 sessions weekly for 5 months

2. Conventional SLT: 2 sessions weekly for 5 months
STACDAP SLT: a series of 28 tasks; non-verbal, phonology, lexical-semantics and morphosyntax of increasing complexity
Conventional SLT: conventional stimulation therapy
Outcomes
Word discrimination, body-part identification, Token Test, miscellaneous commands,

reading comprehension, naming, sentence construction, spontaneous speech, STACDAP phonology, lexicon and morphosyntax
Assessed at baseline and at the end of treatment
Notes
The Netherlands
Participants in additional no treatment group were not randomly allocated but matched
to other groups, and were therefore excluded from the review
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Unclear
Outcome assessor blinding not reported

All outcomes
Yes
Yes
Free of other bias?
Unclear
STACDAP SLT group were older than the conventional SLT

group at baseline

64
Pulvermuller 2001
Methods
Parallel group RCT
Participants
Inclusion criteria: single left MCA stroke, monolingual, competent German speakers
Exclusion criteria: severe cognitive or perceptual difficulties affecting participation, left
handed, additional neurological diseases, depression
Constraint-induced SLT group were longer since stroke (mean 98.2 (74.2) months) than
conventional SLT group (mean 24 (20.6) months)
Interventions
1. Constraint-induced SLT: 3 to 4 hours daily for 10 days

2. Conventional SLT: 2 to 3 hours daily for approximately 4 weeks
Constraint-induced SLT: small groups (2 to 3 participants) with speech and language
therapist involving barrier therapeutic games; all communication verbal, pointing or
gestures not permitted
Conventional SLT: syndrome-specific intervention for example naming, repetition, sentence completion, following instructions, conversation topics of participants own choice
Outcomes
Aachen Aphasia Test (Token Test, comprehension, repetition, naming), Communicative

Activity Log
Assessed at baseline and at end of treatment
Notes
Germany
Risk of bias
Item
Authors judgement
Description
Yes
Computer-generated
Yes
Blinding?
All outcomes
Yes

All outcomes
Yes
Yes
Free of other bias?
No
Constraint-induced SLT group were longer after stroke (mean

98.2 (74.2) months) than conventional SLT Group (mean 24
(20.6) months) at baseline

65
Rochon 2005
Methods
Parallel group RCT
Participants
Inclusion criteria: chronic Brocas aphasia (BDAE), produce sufficient speech for analyses,
single left hemisphere stroke, native English speaker, normal hearing on screening
Interventions
1. Sentence mapping SLT: 1 hour session twice weekly for approximately 2.5 months
2. Social support and stimulation: 1 hour session twice weekly for approximately 2.5
months
Sentence mapping SLT: 4 levels of treatment: active, subject cleft, passive, object cleft
sentences
Social support and stimulation: unstructured conversation about current events; participants were given a narrative retelling task on alternate sessions
Outcomes
Trained sentence structures: (1) active, (2) subject cleft, (3) passive, (4) object cleft; Caplan and Hanna Sentence Production Test; Picture Description and Structure Modeling
Test; narrative task: (1) mean length of utterance, (2) percentage words in sentences, (3)
percentage well formed words, (4) sentence elaboration index; Philadelphia Comprehension Battery (reversible sentences); Picture Comprehension Test
Assessed at baseline, end of treatment and 4-week follow up
Social support and stimulation group also participated in between level probes
Notes
Canada
Only 1 group 1 participant entered all 4 levels; 1 only entered levels 1 and 2 (did not
need levels 3 to 4); 1 participant entered levels 1, 2 and 4
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
No
Outcome assessor blinding inadequate

Primary examiner scored all outcome measures
A fifth of measures were also scored by independent assessor
Point-to-point agreement was 98%

All outcomes
Yes
Unclear
Free of other bias?
Unclear

66
Shewan 1984i
Methods
Parallel group RCT (stratified for type and severity of aphasia)
Participants
Inclusion criteria: unilateral first CVA, Global, Brocas, Wernickes, anomic, conduction
per WAB, occlusive/stable intracerebral haemorrhagic stroke, functional English speakers
Exclusion criteria: non-stroke, symptoms lasting fewer than 5 days, language recovery
within 2 to 4 weeks post-onset, unstable illness, arteriovenous malfunction, aneurysm
rupture, subarachnoid haemorrhage, hearing or visual impairment, WAB aphasia quotient at or above 93.8
Interventions
1. Language-orientated SLT: 1 hour session 3 times weekly* for 1 year

2. Conventional SLT: 1 hour session 3 times weekly* for 1 year
*(or 1.5 hours twice weekly)
Language-orientated SLT: based on psycholinguistic principles provided by speech and
language therapists
Conventional SLT: stimulation-facilitation therapy based on Schuell and Wepmans approaches provided by speech and language therapists
Outcomes
Western Aphasia Battery, Auditory Comprehension Test for Sentences

Assessed at baseline, 3, 6 and 12 months
Notes
Canada
Participants refusing or unable to participate were allocated to a third no-treatment
group. This group were not included in this review
Drop-outs: 7 participants (language-orientated SLT 6; conventional SLT 1)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Unclear
Outcome assessor blinding unclear

All outcomes
No
Unclear
Data reported unsuitable for inclusion

within the review
Free of other bias?
Unclear


67
Shewan 1984ii
Methods
Participants
Inclusion criteria: unilateral first CVA, Global, Brocas, Wernickes, anomic, conduction
per WAB, occlusive/stable intracerebral haemorrhagic stroke, functional English speakers
within 2 to 4 weeks post-onset, unstable illness
Interventions
1. Language-orientated SLT: 1-hour session 3 times weekly* for 1 year

2. Social stimulation and support: 1-hour session 3 times weekly* for 1 year
*(or 1.5 hours twice weekly)
Language-orientated SLT: based on psycholinguistic principles provided by speech and
language therapists
Social stimulation and support: based on stimulation orientation, providing psychological support, communication in unstructured settings carried out by nurses
Outcomes

Notes
Canada
Participants refusing or unable to participate were allocated to a third no-treatment group
but were not included in this review
Drop-outs: 12 participants (language-orientated SLT 6; social stimulation and support
6)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Unclear

All outcomes
No
Unclear

within the review
Free of other bias?
Unclear


68
Shewan 1984iii
Methods
Participants
Inclusion criteria: unilateral first stroke, Global, Brocas, Wernickes, anomic, conduction
as per WAB, occlusive or stable intracerebral haemorrhagic stroke, functional English
speakers
within 2 to 4 weeks after stroke, unstable illness
Interventions
1. Conventional SLT: 1 hour 3 times weekly for 1 year (or 1.5 hours twice weekly)
2. Social stimulation and support: 1 hour 3 times weekly for 1 year (or 1.5 hours twice
weekly)
Conventional SLT: stimulation-facilitation therapy based on Schuell and Wepmans approaches provided by speech and language therapists
Social stimulation and support: based on stimulation orientation, providing psychological support, communication in unstructured settings carried out by nurses
Outcomes

Notes
Canada
Participants refusing or unable to participate were allocated to a third no-treatment group
but were not included in this review
Drop-outs: 7 participants (conventional SLT 1; social stimulation and support 6)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Unclear

All outcomes
No
Unclear

within the review
Free of other bias?
Unclear
Sample size calculation not reported.


69
Smania 2006
Methods
Parallel group RCT
Participants
Inclusion criteria: left unilateral CVA, limb apraxia lasting a minimum of 2 months,
aphasia
Exclusion criteria: previous CVA or other neurological disorders, > 80 years of age, uncooperative, orthopedic or other disabling disorders
Interventions
1. Conventional SLT: 50 minutes 3 times weekly for 10 weeks

2. No SLT: limb apraxia therapy over 10 weeks
Conventional SLT: based on Basso et al 1979 approach
No SLT: limb apraxia therapy only
Outcomes
Token Test, Gestural comprehension (not described)

Assessed at baseline, end of treatment and 2-month follow up
Notes
Italy
All participants had apraxia
Risk of bias
Item
Authors judgement
Description
Yes
No
Co-ordinating trialist allocated participants to groups
Blinding?
All outcomes
Yes

All outcomes
No
ITT was not used
Unclear
Free of other bias?
Unclear

Smith 1981i
Methods
Parallel group RCT (subgroup within larger trial)
Participants
Inclusion criteria: hospital catchment area, measurable residual neurological deficit, no

life threatening concurrent illness, fit for intensive therapy, independent prior to stroke,
inpatient for not more than 2 months after stroke

70
Smith 1981i
(Continued)
Exclusion criteria: too old or frail to travel to hospital, some non-described reasons
Group 1 (intensive SLT) had higher mean percentage error scores on MTDDA than
group 2 (no SLT)
Interventions
1. Intensive SLT: 1 hour 4 times weekly for up to 12 months

2. No SLT
Intensive SLT: not described
No SLT: participants were visited at home by health visitor but frequency is unclear
Outcomes
Minnesota Test for the Differential Diagnosis of Aphasia, General Health Questionnaire
Assessed at baseline, 3, 6 and 12 months after trial admission
Notes
UK
Difficult to maintain intensive SLT input after first 3 months
Participants were also receiving physiotherapy and occupational therapy
No restrictions on other treatments prescribed by hospital staff or GP
Drop-outs: 10 plus ? (5 participants withdrawn prior to final analyses (3 with dysarthria
but no aphasia; 2 died before first re-assessment but grouping not advised) plus intensive
SLT 10; no SLT: none reported
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
No
Outcome assessors not blinded

All outcomes
No
Unclear
Free of other bias?
Unclear
20 patients in main trial had mild dementia, unclear whether any were participants
with aphasia
Group 1 (intensive SLT) had lower mean
percentage error scores on MTDDA than
group 2 (no SLT); it is unclear whether this
was a significant difference

71
Smith 1981ii
Methods
Participants
Inclusion criteria: lives in hospital catchment area, measurable residual neurological

deficit, no life-threatening concurrent illness, fit for intensive therapy if assigned, independent prior to stroke, inpatient for not more than 2 months post-onset
Group 1 (conventional SLT) had higher mean percentage error scores on MTDDA than
group 2 (no SLT)
Interventions
1. Conventional SLT: 40 minutes twice weekly for up to 12 months

2. No SLT
Conventional SLT: not described
No SLT: participants were visited at home by health visitor but frequency is unclear
Outcomes
Notes
UK
Participants also receiving physiotherapy and occupational therapy
No restrictions of other treatments prescribed by the hospital or GP
Drop-outs: 5 participants withdrawn prior to final analyses (3 with dysarthria but no
aphasia; 2 died before first re-assessment but grouping not advised) plus 6 participants
(conventional SLT 6; no SLT: none reported)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
No

All outcomes
No
Unclear
Free of other bias?
Unclear
with aphasia
Group 1 (conventional SLT) had higher
mean percentage error scores on MTDDA
than group 2 (no SLT)

72
Smith 1981ii
(Continued)
Smith 1981iii
Methods
Participants
Inclusion criteria: lives in hospital catchment area, measurable residual neurological

deficit, no life-threatening concurrent illness, fit for intensive therapy if assigned, independent prior to stroke, inpatient for not more than 2 months post-onset
Interventions
1. Intensive SLT: 1 hour 4 times weekly for up to 12 months

2. Conventional SLT: 40 minutes twice weekly for up to 12 months
Intensive SLT: not described
Conventional SLT: not described
Outcomes
Notes
UK
Distinction between intensive and conventional became impossible to maintain after
first 3 months as individual patterns of therapy attendance emerged; in first 3 months
mean 21/50 hours intended
Conventional SLT group received additional group treatment; also received physiotherapy and occupational therapy
No restrictions of other treatments prescribed by the hospital or GP
Drop-outs: 5 participants withdrawn prior to final analyses (3 with dysarthria but no
aphasia; 2 died before first re-assessment but grouping not advised) plus 16 participants
(intensive SLT 10; conventional SLT 6)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
No

All outcomes
No
Unclear

73
Smith 1981iii
(Continued)
Free of other bias?
Unclear
with aphasia
van Steenbrugge 1981

Methods
Parallel group RCT
Participants
Inclusion criteria: neurologically stable, > 3 months after stroke, aphasia, motivated, clear
but not too severe naming difficulties
Interventions
1. Task-specific SLT: 1 hour twice weekly for 6 weeks (followed by 3 weeks free therapy
from patients own therapists)
2. Conventional SLT: unclear but continued for 9 weeks
Task-specific SLT: for naming and constructing sentences: Phase 1 delivered by research
speech and language therapists, Phase 2 delivered by participants own therapist
Conventional SLT: expressive tasks (no details)
Outcomes
FE-Scale (expression), naming (test not specified), sentence construction (not described)
Assessed at baseline, 6 and follow up at 9 weeks
Notes
The Netherlands
Translated by Mrs Christine Versluis (Netherlands)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Unclear

All outcomes
Yes
Unclear
Free of other bias?
Unclear
Groups comparable at baseline (age, time post-stroke)


74
Wertz 1981
Methods
Parallel group RCT
Participants
Inclusion criteria: male veteran, aged 40 to 80 years old, premorbidly literate in English,
first thromboembolic left CVA, no co-existing major medical complications, hearing no
worse than 40 dB in poorer ear, corrected vision no worse than 20/100 in poorer eye,
adequate sensory/motor ability in 1 hand to write/gesture, 4 weeks post-onset, language
severity 15th to 75th overall percentile on PICA
Interventions
1. Group SLT: 4 hours in group with therapist plus 4 hours of group activities weekly
for up to 44 weeks
2. Conventional SLT: 4 hours with therapist plus 4 hours machine-assisted treatment
and SLT drills weekly for up to 44 weeks
Group SLT: each week, 4 hours direct SLT contact in groups of 3 to 7 participants
designed to stimulate language through social interaction; no direct manipulation of
deficits; encouraged group discussion on current events and topics; no direct attempts
to improve or correct incorrect responses; in addition, 4 hours of group recreational
activities weekly
Conventional SLT: direct, stimulus-response manipulation of speech and language
deficits plus 4 hours of machine-assisted treatment and SLT drill
Outcomes
Porch Index of Communicative Ability, Token Test, word fluency measure, Conversational Rating, Informants ratings of functional language use
Assessed at baseline and every 11 weeks until end of 44-week treatment or withdrawal
of participant
Notes
USA over 5 sites

Drop-outs: 33 participants (group SLT 16; conventional SLT 17)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Yes

All outcomes
No
Unclear
Some statistical data included within the review

75
Wertz 1981
(Continued)
Free of other bias?
Unclear

Wertz 1986i
Methods
review)
Participants
Inclusion criteria: male veteran, maximum 75 years old, 2 to 24 weeks post-onset, single
left thromboembolic CVA, no previous or co-existing neurologic, serious medical or
psychological disorder, no worse than 20/100 corrected vision in better eye, hearing no
worse than 40 dB unaided in better ear, sensory/motor ability in 1 upper limb to gesture
or write, premorbidly literate in English, maximum 2 weeks between onset and trial entry,
language severity 10th to 80th PICA overall, non-institutionalised living environment,
outside assistant volunteer available
Exclusion: none listed
Interventions
1. Conventional SLT: 8 to10 hours weekly for 12 weeks

2. No SLT: deferred SLT for 12 weeks
Conventional SLT: delivered by therapist in clinic; stimulus-response (auditory comprehension, reading, oral-expressive language and writing); aphasia-specific techniques;
followed by 12 weeks of no SLT
Outcomes
Porch Index of Communicative Ability, Communicative Abilities in Daily Living, Reading Comprehension Battery for Aphasia, Token Test
Assessed at baseline, 6 and 12 weeks with follow ups at 18 and 24 weeks
Notes
USA over 5 sites

Estimated sample size
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Yes

All outcomes
No

76
Wertz 1986i
(Continued)
Yes
Free of other bias?
Yes
Wertz 1986ii
Methods
review)
Participants
Inclusion criteria: male veteran, maximum 75 years old, 2 to 24 weeks post-onset, single left thromboembolic CVA, no previous neurologic involvement/co-existing serious
medical or psychological disorder, no worse than 20/100 corrected vision in better eye,
hearing no worse than 40 dB unaided in better ear, sensory/motor ability in 1 upper
limb to gesture/write, premorbidly literate in English, maximum 2 weeks between onset
and trial entry, language severity 10th to 80th PICA overall, non-institutionalised living
environment, outside assistant volunteer available
Interventions
1. Volunteer-facilitated SLT: 8 to 10 hours weekly for 12 weeks

2. No SLT: deferred conventional SLT
Volunteer-facilitated SLT: planned and directed by speech and language therapist, administered at home by trained volunteer (family member/friend) with no previous healthcare
experience, followed by 12 weeks of no SLT
Volunteers received 6 to10 hours training, information about aphasia, observation of
treatment on videotapes, demonstration and practise with techniques; weekly face-toface and telephone contact with SLT for advice and support; every 2 weeks volunteers
videotaped a session to be reviewed with SLT and adjustments suggested
Outcomes
Notes
USA over 5 sites

Drop-outs: 18 participants (trained volunteer SLT 7; no SLT 11)
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear

77
Wertz 1986ii
(Continued)
Blinding?
All outcomes
Yes

All outcomes
No
Unclear
Free of other bias?
Unclear
Wertz 1986iii
Methods
review)
Participants
Inclusion criteria: male veteran, maximum 75 years old, 2 to 24 weeks after single left
thromboembolic stroke, no previous neurologic involvement/co-existing serious medical
or psychological disorder, at least 20/100 corrected vision, hearing at least 40 dB unaided,
sensory/motor ability in 1 upper limb to gesture or write, premorbidly literate in English,
maximum 2 weeks between onset and trial entry, language severity 10th to 80th percentile
on PICA, non-institutionalised living, volunteer available
Interventions
1. Volunteer-facilitated SLT: 8 to 10 hours weekly for 12 weeks

2. Conventional SLT: 8 to 10 hours weekly for 12 weeks
Volunteer-facilitated SLT: prepared by speech and language therapist; administered at
home by trained volunteer (family member/friend) with no previous healthcare experience; followed by 12 weeks of no SLT
Volunteers received 6 to 10 hours training, information about aphasia, observation of
treatment on videotapes, demonstration and practise with techniques; weekly face-toface and telephone contact with SLT for advice and support; every 2 weeks volunteers
videotaped a session to be reviewed with SLT and adjustments suggested
Conventional SLT: delivered by therapist in clinic; stimulus-response (auditory comprehension, reading, oral-expressive language and writing); aphasia-specific techniques;
followed by 12 weeks of no SLT
Outcomes
Notes
USA over 5 sites

Drop-outs: 16 participants (Volunteer-facilitated SLT 9; conventional SLT 7)
Risk of bias
78
Wertz 1986iii
(Continued)
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Yes

All outcomes
No
Unclear
Free of other bias?
Unclear
Wu 2004
Methods
Parallel group RCT
Participants
Inclusion criteria: none described

Exclusion criteria: none described
Interventions
1. Conventional SLT: frequency of therapy unclear; for 6 months

2. No SLT
Conventional SLT: 2-part intervention including visual stimulation, gesture and word
pattern for comprehension, pronunciation, reading single words and entertainments
(not described) Part 1: inpatient intervention (doctors); Part 2: outpatient intervention
(family members trained by doctors)
Outcomes
None available
Notes
China
Risk of bias
Item
Authors judgement
Description
Unclear
Unclear
Blinding?
All outcomes
Yes

79
Wu 2004
(Continued)

All outcomes
Yes
No
Statistical data not reported
Free of other bias?
Unclear

ADL: activities of daily living

ANELT: Amsterdam-Nijmegen Everyday Language Test
BDAE: Boston Diagnostic Aphasia Examination
CADL: communicative abilities of daily living
CETI: Communicative Effectiveness Index
CVA: cerebrovascular accident
dB: decibels
GP: general practitioner
ITT: intention-to-treat
MCA: middle cerebral artery
MTDDA: Minnesota Test for the Differential Diagnosis of Aphasia
NHS: National Health Service (UK)
PALPA: psycholinguistic assessments of language processing in aphasia
PICA: Porch Index of Communicative Abilities
RCT: randomised controlled trial
SD: standard deviation
SLT: speech and language therapy/therapist
SPICA: Shortened Porch Index of Communicative Abilities
STACDAP: systematic therapy for auditory comprehension disorders in aphasic patients
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Cherney 2007
Experimental and control groups had same SLT intervention with experimental group also receiving cortical
stimulation
Cohen 1992
Included conditions other than stroke

Unable to obtain aphasia-specific data
Cohen 1993

Gu 2003
Hartman 1987
Quasi -randomisation

80
(Continued)
Jungblut 2004
Randomisation to groups not adequate: group allocation could be predicted
Kagan 2001
Quasi-randomisation
Kalra 1993
Not all participants had aphasia

Kinsey 1986
Randomisation dictated order of task presentation

Aimed to establish impact of task delivery on performance
Not a therapeutic intervention
Meinzer 2005
Randomisation to groups inadequate; group allocation could be predicted
Rudd 1997
Stoicheff 1960

Wang 2004
Not all participants had aphasia

Wolfe 2000
Wood 1984

Zhang 2004
Unable to obtain aphasic-specific data
SLT: speech and language therapy
Characteristics of studies awaiting assessment [ordered by study ID]

Liu 2006
Methods
Aphasia rehabilitation programme, 30 to 60 minutes daily or every other day
Participants
Interventions
1. SLT aphasia rehabilitation

2. Control
Outcomes
Unclear
Follow-up measures at 3 months

81
Liu 2006
(Continued)
Notes
Characteristics of ongoing studies [ordered by study ID]

ACTNow
Trial name or title
ACTNow: Assessing the effectiveness of Communication Therapy in the North west
Methods
Pragmatic, multi-centre RCT with a nested qualitative study and full economic evaluation
Participants
170 (revised from 330)
Interventions
1. Early SLT from NHS therapists; up to 3 sessions per week for maximum of 16 weeks
2. Control group: similar level of contact with a visitor (paid part-time staff ) trained to deliver a manualised
attention control
Outcomes
Primary outcome: functional communication; expert blinded therapist rating of semi-structured conversation
using Therapy Outcomes Measures Scale (TOMS)
Secondary outcome: participant and carers own perception of functional communication and quality of life
Costs of communication therapy compared to that of attention control
Starting date
October 2006
Contact information
Emma Patchick or Audrey Bowen

emma.patchick@manchester.ac.uk or audrey.bowen@manchester.ac.uk
http://www.psych-sci.manchester.ac.uk/actnow/
Notes
Expected completion: 2010
IHCOP
Trial name or title
The effects of phoneme discrimination and semantic therapies for speech perception deficits in aphasia
Methods
Participants
20
Interventions
1. Phoneme discrimination therapy, e.g. discrimination tasks or matching spoken to written words
2. Semantic therapy, e.g. word to picture matching with provided semantic context
Outcomes
Minimal pair discrimination with pictures

Lexical decision
Synonym judgement

82
IHCOP
(Continued)
Telephone message task

Control task: written sentence to picture matching
Treated versus untreated words using a cross-modal priming task
Starting date
February 2006
Contact information
Dr Celia Woolf
Notes
Kukkonen 2007
Trial name or title
Methods
40 participants with aphasia randomised into 4 groups that vary in the intensity of SLT allocated and in the
onset of therapy
Participants have also been stratified by age: younger group (50 to 65 years) and older group (66 to 80 years)
SLT was provided over a 1-year period with periods of therapy sessions and family counselling
Participants
Inclusion criteria: aged 50 to 80 years old, first CVA in the left hemisphere, living locally, diagnosis in university
hospital, diagnosis confirmed by CT/MRI, availability of a relative
Interventions
1. High intensity SLT: 45 minutes 2 times per day, 5 days per week for 6 weeks
2. Moderate intensity SLT: 45 minutes 2 times per day, 2 days per week for 6 weeks
3. Conventional SLT: 45 minutes per week for 6 weeks
4. Control group: no individual SLT
Spouses or carers received support and information from the speech and language therapists 3 times
Outcomes
Speech comprehension (Token Test, BDAE)

Speech production (BDAE and BNT), story telling from cartoon frames
Functional communicative skills (CETI)
Functional Independence Measurement and 15D
Pizzamigglio Sentence Test
Quick Aphasia Screening Test
Montgomery & berg Depression scale and with Beck s Depression scale
Assessments were administered at 1 week, 1, 4, 7 and 13 months post-stroke
Each participants had a 1.5 year follow up
Starting date
Contact information
Tarja Kukkonen
Speech Therapist, Lecturer in Logopedics
Puheopin laitos
33014 Tampereen yliopisto
Finland
Tel. +358 3 35514086
Tarja.Kukkonen@uta.fi

83
Kukkonen 2007
(Continued)
Notes
Laska 2008
Trial name or title
Early speech and language therapy in patients with acute stroke and aphasia
Methods
Patients stratified according to NIHSS result

Randomised by use of consecutive sealed envelopes
Outcome measures conducted and assessed by blinded speech and language therapists
Participants
Consecutive admissions to Stroke Unit

Inclusion criteria: first ischaemic stroke with aphasia, can start SLT within 2 days of stroke onset
Exclusion criteria: dementia, drug abuse, unable to participate in therapy
Interventions
1. Early Intensive SLT (language enrichment therapy): 45 minutes per day for 15 working days
2. No SLT for 3 weeks
Outcomes
Primary outcome: ANELT at day 16 Secondary outcome: Norsk Grunntest for Afasi (NGA) at day 16
Other measures include NIHSS, ADL measured at baseline, 3 weeks and 6 months, NGA, ANELT, Nottingham Health Profile (NHP), EuQoL at 3 weeks and 6 months
Relatives complete the CETI at 3 weeks and 6 months
Starting date
Recruitment complete
Contact information
Ann Charlotte Laska

Department of Internal Medicine
Danderyd Hospital
Stockholm
Sweden
Tel: +46 8 655 6409
ann-charlotte.laska@ds.se
Notes
Funded by the Stockholm County Council Foundation (Expo-95), Karolinska Institutet, Marianne and
Marcus Wallenberg Foundation and AFA Insurances
Results expected Autumn 2009
Maher 2008
Trial name or title
An investigation of constraint-induced language therapy for aphasia
Methods
2 different intensities of therapy
Participants
48 participants collected at 3 sites (Houston, Gainesville and Tampa VAMCs)

Inclusion criteria: moderate - moderately severe, non-fluent aphasia, unilateral left CVA, right-handed, English
as first language, adequate hearing and vision to participate in therapy
Exclusion criteria: multiple strokes, history of other neurological impairment, non-English speaking, inadequate auditory comprehension, severe speech apraxia

84
Maher 2008
(Continued)
Interventions
1. Intensive CILT
2. Intensive PACE therapy
3. Distributed CILT
4. Distributed PACE therapy
Outcomes
Language assessment, discourse sample, daily probe measures and qualitative interviews will be used to measure
treatment effects
1-month follow up
Starting date
August 2002
Contact information
Lynn M Maher
Department of Communication Sciences and Disorders
University of Houston
lmmaher@uh.edu
Notes
Completion date: June 2006
RATS2
Trial name or title
RATS2: the efficacy of cognitive linguistic therapy in the acute stage of aphasia: a randomised control trial
Methods
Cognitive linguistic SLT versus conventional SLT (from 3 weeks up to 6 months post-onset)
Participants
80
Interventions
1. Cognitive linguistic therapy (paper and computer) using BOX (lexical semantic treatment programme)
and/or FIKS (phonological treatment programme) or a combination of the two depending on individual
language disorders
2. Control group: communicative therapy targeting verbal and nonverbal strategies to communicate message
(e.g. PACE); no focus on semantics, phonology or syntax is permitted
Outcomes
Primary outcome: ANELT-A

Secondary outcome: Verbal Semantic Association Task (SAT), semantic association of words with low imageability (PALPA), non-words repetition (PALPA) and auditory lexical decision (PALPA), semantic word
fluency, letter fluency and Boston Naming Test
Starting date
September 2006
Contact information
Dr EG Visch-Brink
e.visch-brink@erasmusmc.nl
Dr M de Jon-Hagelstein
m.hagelstein@erasmusmc.nl
http://www.controlled-trials.com/ISRCTN67723958
Notes
Results available at the end of 2009

85
RATS3
Trial name or title
The efficacy of cognitive linguistic therapy in the acute stage of aphasia: a randomised control trial
Methods
Cognitive linguistic SLT versus no SLT

Massed practice: 2 weeks post-onset up to 2 months post-onset
Participants
80
Interventions
1. Cognitive linguistic therapy: BOX (semantic therapy) or/and FIKS (phonological therapy) for 6 weeks
2. No SLT: deferred SLT after 6 weeks
Outcomes
Primary outcome: ANELT-A

Secondary outcome: Verbal Semantic Association Test (SAT), semantic Association of words with low imageability (PALPA), non-words repetition (PALPA), Auditory Lexical Decision (PALPA), Semantic Word
Fluency, Letter Fluency, Boston Naming Test
Starting date
Autumn 2009
Contact information
EG Visch-Brink e.visch-brink@erasmusmc.nl
M de Jong-Hagelstein m.hagelstein@erasmusmc.nl
http://www.controlled-trials.com/ISRCTN67723958
Notes
Results available at the end of 2012
SEATAS
Trial name or title
Study of Early Aphasia Therapy After Stroke (SEATAS)
Methods
Prospective, randomised, open-label, single-blinded controlled trial
Participants
59 participants with moderate to severe aphasia following stroke
Interventions
1. Intensive daily SLT (32 participants): 30 to 80 minutes 5 days per week up to 4 weeks or 20 sessions
2. Conventional SLT (weekly) (27 participants): 1 session per week up to 4 weeks or 20 sessions
Three therapy types used:
Lexical-sematic (BOX) therapy
Mapping Therapy
Semantic Feature Analysis
All participants had a SLT programme individually tailored to suit their needs and therapists were instructed
to provide treatment from the above therapy types, according the participants needs
The therapist could use only these therapy approaches (one or more)
Therapy types and tasks for each participant were recorded
Picture description task: all participants receiving SLT attempted a picture description task at each session
during the acute hospital stay
Outcomes
Primary outcome measures: Aphasia Quotient (AQ) and Functional Communication Profile (FCP) at acute
hospital discharge
Secondary outcome measures: AQ, FCP and Discourse Analysis (DA) scores at six months post stroke

86
SEATAS
(Continued)
Starting date
Recruitment April 2000 to September 2003
Contact information
Erin Godecke
Human Communication Science, School of Psychology and Speech Pathology
Curtin University of Technology, GPO Box U1987 Perth, Australia
Tel: +61 8 9266 3039
e.godecke@curtin.edu.au
Notes
Results available 2010
SP-I-RiT
Trial name or title
SPeech Intensive Rehabilitation Therapy
Methods
Participants
120
Interventions
To evaluate the efficacy of intensive speech therapy in aphasic stroke patients
Outcomes
Primary outcome: increase of the Aphasia Quotient of at least 15% at the end of therapy
Secondary outcome: differences in Aphasia Quotient defined by Lisbon Aphasia Battery
Sustained improvement in the intensive speech therapy group between 10th and 50th week
Costs of therapy, per therapeutic group
Number of missed therapeutic sessions and non-attendances in each group
Patient satisfaction as measured by patient global impression scale
Starting date
September 2004
Contact information
Dr Martin Lauterbach
email: mlauterbach@fm.ul.pt
http://www.imm.ul.pt
Notes
Varley 2005
Trial name or title
Methods
Self-administered intervention for word production impairments following stroke
Participants
50 participants with apraxia of speech; 20 participants with non-apraxic word production impairments
Interventions
Both interventions self-administered via software programs loaded onto laptop computer
1. Speech program is based around SWORD, a word-level intervention for apraxia of speech
2. Placebo intervention: does not target speech, but trains visual attention and memory

87
Varley 2005
(Continued)
Outcomes
Word production measured across sets of treated, untreated phonetically matched, and untreated phonetically
unmatched words immediately post-treatment and at 8 weeks post-treatment
Word production evaluated for functional adequacy and acoustic measures of speech cohesion
Generalisation to spontaneous speech measured via narrative production
Untreated control behaviours (word reading and spoken sentence comprehension) evaluated
Study also includes health economic assessment
Starting date
June 2008
Contact information
Professor Rosemary Varley, Human Communication

Sciences, University of Sheffield
Notes
Funded by The BUPA Foundation. Expected Completion: October 2010
ADL: activities of daily living

BNT: Boston Naming Test
CETI: Communicative Effectiveness Index
CILT: constraint-induced language therapy
CT: computerised tomography
CVA: cerebrovascular accident
NHS: National Health Service (UK)
NIHSS: National Institutes of Health Stroke Scales
MRI: magnetic resonance imaging
PALPA: psycholinguistic assessments of language processing in aphasia
PACE: promoting aphasics communicative effectiveness therapy
RCT: randomised controlled trial

88
DATA AND ANALYSES
Comparison 1. SLT versus no SLT
Outcome or subgroup title

1 Functional communication
1.1 WAB
1.2 ANELT-A
1.3 Functional
Communication Profile
2 Receptive language: auditory
comprehension
2.1 PICA subtest
2.2 Token Test
3 Receptive language: reading
comprehension
3.1 Reading Comprehension
Battery for Aphasia
3.2 PICA reading subtest
4 Receptive language: other
4.1 PICA Gestural subtest
5 Receptive language: gesture
comprehension (unnamed)
5.1 Gesture (unnamed)
5.2 Gesture (unnamed)
2-month follow up
6 Expressive language: naming
6.1 Boston Naming Test
6.2 WAB Naming subtest
7 Expressive language: general
7.1 PICA Verbal subtest
8 Expressive language: written
8.1 PICA Copying subtest
8.2 PICA Writing subtest
8.3 PICA Graphic
9 Expressive language: repetition
9.1 WAB Repetition subtest
10 Severity of impairment:
Aphasia Battery Score (+ PICA)
10.1 Aphasia Quotient
(CRRCAE)
10.2 Porch Index of
Communicative Ability
11 Severity of impairment: Aphasia
Battery Score (3-month follow
up)
(CRRCAE) 3-month follow up
No. of
studies
No. of
participants
5
2
1
2
176
55
18
103
Std. Mean Difference (IV, Fixed, 95% CI)

0.28 [-0.03, 0.59]

0.14 [-0.40, 0.69]
0.88 [-0.10, 1.87]
0.25 [-0.16, 0.66]
191
0.10 [-0.20, 0.39]
2
3
4
55
136
158

0.15 [-0.40, 0.69]

0.08 [-0.27, 0.43]
0.11 [-0.21, 0.44]
103
0.11 [-0.30, 0.52]
2
4
4
1
55

Mean Difference (IV, Fixed, 95% CI)
0.12 [-0.42, 0.67]

Subtotals only
8.04 [1.55, 14.52]
Subtotals only
158
Statistical method
Effect size
1
1
33
17

-0.92 [-2.19, 0.35]

-1.14 [-3.23, 0.95]
3
1
2
4
4
4
2
2
2
2
2
6
73
18
55
158
158
55
249

0.20 [-0.27, 0.68]

-0.00 [-0.93, 0.93]
0.27 [-0.27, 0.82]
5.28 [-1.33, 11.89]
5.28 [-1.33, 11.89]
Subtotals only
3.88 [-5.75, 13.50]
8.38 [-4.47, 21.22]
5.15 [-3.64, 13.94]
Subtotals only
0.92 [-0.76, 2.61]
0.18 [-0.09, 0.44]
84
0.02 [-0.43, 0.47]
165
0.26 [-0.07, 0.58]
Mean Difference (IV, Random, 95% CI)
Subtotals only
Mean Difference (IV, Random, 95% CI)
20.74 [-12.01,
53.48]
55
55
103
84

89
12 Psychosocial: MAACL
12.1 Anxiety Scale (MAACL)
12.2 Depression Scale
(MAACL)
12.3 Hostility Scale (MAACL)
13 Number of drop-outs (any
reason)
1
1
1
137
137

Subtotals only
0.40 [-0.57, 1.37]
0.70 [-1.38, 2.78]
1
10
137
714

Odds Ratio (M-H, Fixed, 95% CI)
-0.10 [-0.90, 0.70]

0.86 [0.61, 1.20]
Comparison 2. SLT versus social support and stimulation
No. of
studies
No. of
participants
1.1 Functional
1.2 FCP (3-month follow up)
1.3 FCP (6-month follow up)
comprehension
2.1 Sentence Comprehension
Test (PCB)
2.2 Picture Comprehension
Test (PCB)
2.3 Token Test
1
1
96

3.1 PICA Gestural subtest
4 Expressive language: single words
4.1 Object Naming Test
(ONT)
4.2 Word fluency
5 Expressive language: sentences
5.1 Caplan & Hanna Test:
total
treated
untreated
6 Expressive language: picture
description
6.1 Picture description
6.2 Picture description with
structure modelling: treated
items
6.3 Picture description with
structure modelling: untreated
items
1
1
1
1
Statistical method
Effect size

Subtotals only
-2.20 [-10.75, 6.35]
1
1
2
73
73

1.40 [-8.01, 10.81]

1.30 [-8.07, 10.67]
Subtotals only
6.00 [-12.94, 24.94]
8.0 [-10.94, 26.94]
18

-3.83 [-18.95,
11.29]
Subtotals only
-0.87 [-1.70, -0.04]
Subtotals only
-5.00 [-11.67, -2.33]
-14.0 [-20.35, -7.65]
Subtotals only
2.0 [-2.73, 6.73]
18
18
1
1
1
18
5

3.00 [0.63, 5.37]
-1.0 [-5.31, 3.31]
Subtotals only
2
2
1
23
5

0.26 [-0.62, 1.15]

0.45 [-1.44, 2.33]
0.41 [-1.46, 2.28]

90
7 Expressive language: overall

spoken
7.1 PICA verbal subtest
8.1 PICA graphic subtests
Battery Score
9.1 PICA
10 Number of drop-outs for any
reason
1
1
1
1
1
18
1
4
18
260
18
Subtotals only

-1.56 [-2.46, -0.66]

Subtotals only
-1.39 [-2.49, -0.29]
Subtotals only

Odds Ratio (M-H, Random, 95% CI)
-1.13 [-1.91, -0.35]

0.65 [0.38, 1.12]
Comparison 3. Functional SLT (SLTA) versus conventional SLT (SLTB)

1.1 CADL (change from
baseline)
1.2 CETI
2 Functional communication:
catalogue ordering
2.1 Telephone order (change
from baseline)
2.2 Telephone order (+
concurrent task) (change from
baseline)
2.3 Written order (change
from baseline)
2.4 Written order (+
concurrent task) (change from
baseline)
3 Expressive language: spoken
3.1 Oral naming: PALPA
(change from baseline)
4.1 Written naming: PALPA
No. of
studies
1
1
No. of
participants
12
Statistical method
Effect size

Subtotals only
-9.3 [-15.01, -3.59]
1
1
12

-3.90 [-8.65, 0.85]

Subtotals only
12
32.8 [16.16, 49.44]
12
16.9 [1.31, 32.49]
12
-5.00 [-19.81, 9.81]
12
9.8 [-10.13, 29.73]
1
1
12

Subtotals only
6.0 [-8.21, 20.21]
1
1
12

Subtotals only
-2.20 [-11.26, 6.86]

91
Comparison 4. Intensive SLT (SLTA) versus conventional SLT (SLTB)

comprehension (change from
baseline)
1.1 AAT Comprehension
subtest
1.2 Token Test
(change from baseline scores)
2.1 Naming subtest (AAT)
2.2 Repetition subtest (AAT)
3 Written language: (change from
baseline scores)
3.1 Written subtest (AAT)
Battery Score
4.1 Aphasia Quotient (WAB)
4.2 AAT profile (change from
baseline)
4.3 Aphasia Quotient (WAB)
3-month follow up
reason
No. of
studies
No. of
participants
Statistical method
Effect size
Subtotals only
17
10.3 [-0.52, 21.12]
1
1
17

6.2 [-3.32, 15.72]

Subtotals only
1
1
1
17
17

5.70 [-1.69, 13.09]

2.80 [-3.86, 9.46]
Subtotals only
1
3
17

8.9 [1.81, 15.99]

Subtotals only
2
1
86
17

2.00 [-8.21, 12.20]

5.70 [-0.76, 12.16]
66
1.90 [-10.53, 14.33]
127
2.10 [0.99, 4.46]
Comparison 5. Volunteer-facilitated SLT (SLTA) versus professional SLT (SLTB)

1.1 CADL
1.2 Functional
comprehension
2.1 Token Test
2.2 AAT subtest
comprehension
3.1 Reading Comprehension
Battery for Aphasia
4.1 PICA gestural subtest
No. of
studies
No. of
participants
1
1
1
68
68
Statistical method
Effect size

Subtotals only
1.64 [-11.70, 14.98]
2.70 [-7.16, 12.56]
Subtotals only
2
1
1
88
20

0.06 [-0.36, 0.47]

-0.37 [-1.25, 0.52]
Subtotals only
68
0.34 [-8.64, 9.32]
1
1
2
68
68

-2.54 [-13.18, 8.10]

-2.54 [-13.18, 8.10]
Subtotals only

92
5.1 AAT naming subtest

6.1 AAT Repetition subtest
7.1 AAT written language
subtest
7.2 PICA graphic subtests
Battery Score
8.1 PICA
8.2 AAT
reason
1
1
1
1
2
1
20
68
20

8.40 [-12.68, 29.48]

0.93 [-8.18, 10.04]
Subtotals only
13.5 [0.19, 26.81]
Subtotals only
9.5 [-11.63, 30.63]
1
3
68
126

2.22 [-6.90, 11.34]

-0.12 [-0.47, 0.23]
2
1
3
106
20
206

-0.06 [-0.44, 0.32]

-0.45 [-1.34, 0.44]
1.05 [0.54, 2.04]
20
Comparison 6. Group SLT (SLTA) versus 1-to-1 SLT (SLTB)

comprehension
1.1 Token Test
1.2 AAT comprehension
subtest
3.1 AAT naming subtest
4.1 AAT repetition subtest
5.1 PICA graphic
Battery Score
CRRCAE
6.2 PICA overall
6.3 AAT overall
Battery Score (3-month follow
up)
CRRCAE (3-month follow up)
reason
No. of
studies
No. of
participants
2
2
1
51
17
Statistical method
Effect size
Subtotals only

0.25 [-0.30, 0.81]

0.47 [-0.51, 1.45]
Subtotals only
1.78 [-15.51, 19.07]
Subtotals only
0.34 [-0.64, 1.31]
0.04 [-0.63, 0.71]
-0.64 [-7.27, 5.99]
-0.64 [-7.27, 5.99]
Subtotals only
-6.03 [-20.67, 8.61]
0.17 [-0.22, 0.56]
1
1
2
1
1
1
1
1
1
3
34
105

54
0.30 [-0.24, 0.84]
1
1
1
34
17

-0.06 [-0.73, 0.61]

0.23 [-0.74, 1.20]
Subtotals only
54
33.41 [16.76, 50.06]
67
0.94 [0.36, 2.46]
34
17
34
17
17

93
Comparison 7. Task-specific SLT (SLTA) versus conventional SLT (SLTB)

1.1 Functional expression
comprehension - word
2.1 Word comprehension
(BDAE subtest)
2.2 Identify body part (BDAE
subtest)
2.3 Peabody PVT
auditory comprehension
3.1 Sentence comprehension
3.2 AAT comprehension
subtest
3.3 Token Test
comprehension (treated items)
(phonology)
(lexicon)
4.3 Sentence comprehension
(morphosyntax)
comprehension
5.1 Reading comprehension
naming
7.1 Naming
7.2 Naming (3-week follow
up)
sentence construction
8.1 Sentence construction
(AmAT)
(AmAT) 3-week follow up
9 Expressive language: other
spoken tasks
9.1 Word fluency
No. of
studies
No. of
participants
2
2
2
31

Subtotals only
-0.25 [-0.96, 0.46]
Subtotals only
33
-0.02 [-0.70, 0.67]
21
-0.22 [-1.08, 0.64]
1
5
12

0.13 [-1.01, 1.26]

Subtotals only
1
1
21
17

-0.51 [-1.39, 0.36]

0.47 [-0.51, 1.45]
5
1
74

-0.00 [-0.46, 0.46]

Subtotals only
21
-2.0 [-8.45, 4.45]
21
-5.0 [-22.80, 12.80]
21

-12.00 [-52.89,
24.89]
Subtotals only

5.0 [-6.51, 16.51]

Subtotals only
-0.29 [-0.97, 0.39]
Subtotals only

0.04 [-0.43, 0.51]

0.70 [-0.60, 2.00]
Subtotals only
1
1
3
3
5
21
5
1
72
10
36
Statistical method
Effect size
31
0.02 [-0.69, 0.72]
10
-0.25 [-1.50, 1.00]
Subtotals only

-1.05 [-1.93, -0.17]

-0.20 [-1.04, 0.64]
-0.31 [-0.99, 0.37]
3
2
2
3
24
24
36

94

(treated items)
10.1 Naming (treated)
(treated)
10.3 Naming (treated: 3-week
follow up)
(treated: 3-week follow up)
11.1 AAT repetition subtest
12.1 PICA graphic subtest
13 Severity of impairment
13.1 PICA overall
13.2 AAT overall
reason
Subtotals only
1
1
10
10

8.0 [-0.46, 16.46]

3.2 [-1.06, 7.46]
10
6.20 [-0.37, 12.77]
10
4.00 [-1.16, 9.16]
1
1
3
3
4
3
1
1
17
17

-0.64 [-7.27, 5.99]

-0.64 [-7.27, 5.99]
Subtotals only
-0.85 [-1.69, -0.01]
Subtotals only
-0.74 [-1.50, 0.01]
1.44 [-4.48, 7.36]
6.27 [0.70, 56.40]
36
36
17
52
Comparison 8. Operant training SLT (SLTA) versus conventional SLT (SLTB)

comprehension
(BDAE subtest)
1.2 Peabody PCT
1.3 Token Test
3.1 Naming
3.2 Word fluency
4.1 PICA graphic subtest
5 Severity of impairment
5.1 PICA overall
No. of
studies
No. of
participants
Statistical method
Effect size
Subtotals only
12
1.5 [-10.73, 13.73]
1
3
3
3
3
3
2
2
3
3
3
3
3
12
36

1.5 [-10.73, 13.73]

4.99 [-7.05, 17.02]
Subtotals only
-0.29 [-0.97, 0.39]
Subtotals only
-0.25 [-0.92, 0.41]
-1.05 [-1.93, -0.17]
-0.20 [-1.04, 0.64]
-0.31 [-0.99, 0.37]
Subtotals only
-0.85 [-1.69, -0.01]
Subtotals only
-0.74 [-1.50, 0.01]
36
36
24
24
36
36
36

95
Comparison 9. Semantic SLT (SLTA) versus phonological SLT (SLT B)

1.1 ANELT-A
2.1 Semantic Association Test:
PALPA (change from baseline)
2.2 Auditory lexical decision:
3.1 Synonym judgement:
4.1 Non-words: PALPA
reason
No. of
studies
1
1
1
1
No. of
participants
Statistical method
Effect size
46

Subtotals only
0.40 [-5.68, 6.48]
Subtotals only
1.30 [-1.00, 3.60]
46
-3.5 [-6.23, -0.77]
1
1
46
46

1.60 [-1.85, 5.05]

1.60 [-1.85, 5.05]
1
1
46

Subtotals only
-1.7 [-4.49, 1.09]
58
1.0 [0.28, 3.56]
55
Comparison 10. Filmed programmed instruction SLT (SLT A) versus non-programmed activity SLT (SLTB)

2.1 Reading comprehension
2.2 Reading recognition
No. of
studies
No. of
participants
1
1
1
1
1
14
14
14
14
Statistical method

Effect size
0.72 [-2.41, 3.85]
0.72 [-2.41, 3.85]
Subtotals only
-0.08 [-1.50, 1.34]
-0.10 [-1.45, 1.25]
96
Analysis 1.1. Comparison 1 SLT versus no SLT, Outcome 1 Functional communication.

Review:
Comparison: 1 SLT versus no SLT

Outcome: 1 Functional communication
Study or subgroup
SLT
No SLT
Std. Mean Difference
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Katz 1997i
10
13.8 (5.3)
15
13.7 (5)
15.1 %
0.02 [ -0.78, 0.82 ]
Katz 1997ii
11
13.8 (5.3)
19
12.2 (6.7)
17.4 %
0.25 [ -0.50, 1.00 ]
32.5 %
0.14 [ -0.40, 0.69 ]
10.0 %
0.88 [ -0.10, 1.87 ]
10.0 %
0.88 [ -0.10, 1.87 ]
1 WAB
Subtotal (95% CI)
21
34
Heterogeneity: Chi2 = 0.17, df = 1 (P = 0.68); I2 =0.0%

Test for overall effect: Z = 0.51 (P = 0.61)
2 ANELT-A
Doesborgh 2004b
Subtotal (95% CI)
34.3 (8.4)
10
25.5 (10.3)
10
Heterogeneity: not applicable

3 Functional Communication Profile
Wertz 1986i
31
59.35 (19.62)
17
55.6 (19.56)
27.5 %
0.19 [ -0.40, 0.78 ]
Wertz 1986ii
37
62.05 (21.83)
18
55.6 (19.56)
30.1 %
0.30 [ -0.27, 0.87 ]
35
57.6 %
0.25 [ -0.16, 0.66 ]
79
100.0 %
0.28 [ -0.03, 0.59 ]
Subtotal (95% CI)
68

Total (95% CI)
97

Test for subgroup differences: Chi2 = 1.70, df = 2 (P = 0.43), I2 =0.0%
-2
-1
Favours No SLT

Favours SLT
97
Analysis 1.2. Comparison 1 SLT versus no SLT, Outcome 2 Receptive language: auditory comprehension.
Review:

Outcome: 2 Receptive language: auditory comprehension
Study or subgroup
SLT
No SLT
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Katz 1997i
10
61.7 (19.8)
15
58.7 (25.3)
13.6 %
0.12 [ -0.68, 0.93 ]
Katz 1997ii
11
61.7 (19.8)
19
57.9 (23.9)
15.8 %
0.16 [ -0.58, 0.91 ]
29.3 %
0.15 [ -0.40, 0.69 ]
1 PICA subtest
Subtotal (95% CI)
21
34

2 Token Test
Smania 2006
15
18.2 (7.65)
18
14.94 (10.23)
18.3 %
0.35 [ -0.34, 1.04 ]
Wertz 1986i
31
118.39 (41.95)
17
119.91 (38.48)
24.9 %
-0.04 [ -0.63, 0.55 ]
Wertz 1986ii
37
119.89 (45.06)
18
119.91 (38.48)
27.5 %
0.00 [ -0.56, 0.56 ]
53
70.7 %
0.08 [ -0.27, 0.43 ]
87
100.0 %
0.10 [ -0.20, 0.39 ]
Subtotal (95% CI)
83

Total (95% CI)
104

-2
-1
Favours No SLT

Favours SLT
98
Analysis 1.3. Comparison 1 SLT versus no SLT, Outcome 3 Receptive language: reading comprehension.
Review:

Outcome: 3 Receptive language: reading comprehension
Study or subgroup
SLT
N
No SLT
Mean(SD)
Mean(SD)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
1 Reading Comprehension Battery for Aphasia

Wertz 1986i
31
76.9 (16.97)
17
75.03 (18.06)
30.5 %
0.11 [ -0.49, 0.70 ]
Wertz 1986ii
37
77.24 (20.79)
18
75.03 (18.06)
33.6 %
0.11 [ -0.45, 0.67 ]
64.1 %
0.11 [ -0.30, 0.52 ]
Subtotal (95% CI)
68
35

2 PICA reading subtest
Katz 1997i
10
69.8 (22.6)
15
69.3 (20.2)
16.7 %
0.02 [ -0.78, 0.82 ]
Katz 1997ii
11
69.8 (22.6)
19
65.1 (22.2)
19.3 %
0.20 [ -0.54, 0.95 ]
34
35.9 %
0.12 [ -0.42, 0.67 ]
69
100.0 %
0.11 [ -0.21, 0.44 ]
Subtotal (95% CI)
21

Total (95% CI)
89

-1
-0.5
Favours No SLT

0.5
Favours SLT
99
Analysis 1.4. Comparison 1 SLT versus no SLT, Outcome 4 Receptive language: other.
Review:

Outcome: 4 Receptive language: other
Study or subgroup
SLT
No SLT
Mean Difference
Weight
IV,Fixed,95% CI
Mean Difference
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Katz 1997i
10
79.8 (14.1)
15
66.3 (21.9)
21.1 %
13.50 [ -0.61, 27.61 ]
Katz 1997ii
11
79.8 (14.1)
19
68.3 (23)
23.8 %
11.50 [ -1.78, 24.78 ]
Wertz 1986i
31
65.32 (19.03)
17
59.68 (20.98)
29.1 %
5.64 [ -6.37, 17.65 ]
Wertz 1986ii
37
62.78 (25.67)
18
59.68 (20.98)
25.9 %
3.10 [ -9.64, 15.84 ]
100.0 %
8.04 [ 1.55, 14.52 ]
1 PICA Gestural subtest
Subtotal (95% CI)
89
69

-50
-25
Favours No SLT
25
50
Favours SLT
Analysis 1.5. Comparison 1 SLT versus no SLT, Outcome 5 Receptive language: gesture comprehension
(unnamed).
Review:

Outcome: 5 Receptive language: gesture comprehension (unnamed)
Study or subgroup
SLT
No SLT
Mean Difference
Mean(SD)
Mean(SD)
15
7.36 (2.17)
18
8.28 (1.36)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Gesture (unnamed)
Smania 2006
Subtotal (95% CI)
15
18
100.0 %
-0.92 [ -2.19, 0.35 ]
100.0 %
-0.92 [ -2.19, 0.35 ]
100.0 %
-1.14 [ -3.23, 0.95 ]
100.0 %
-1.14 [ -3.23, 0.95 ]

2 Gesture (unnamed) 2-month follow up
Smania 2006
Subtotal (95% CI)
6.75 (2.81)
7.89 (1.17)

-10
-5
Favours No SLT

10
Favours SLT
100
Analysis 1.6. Comparison 1 SLT versus no SLT, Outcome 6 Expressive language: naming.
Review:

Outcome: 6 Expressive language: naming
Study or subgroup
SLT
No SLT
Mean(SD)
Mean(SD)
Doesborgh 2004b
75.6 (38.7)
10
75.7 (36.7)
Subtotal (95% CI)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
1 Boston Naming Test
10
25.8 %
0.00 [ -0.93, 0.93 ]
25.8 %
0.00 [ -0.93, 0.93 ]

2 WAB Naming subtest
Katz 1997i
10
7 (2.4)
15
6.9 (2.8)
34.9 %
0.04 [ -0.76, 0.84 ]
Katz 1997ii
11
7 (2.4)
19
5.5 (3.3)
39.3 %
0.48 [ -0.27, 1.24 ]
34
74.2 %
0.27 [ -0.27, 0.82 ]
44
100.0 %
0.20 [ -0.27, 0.68 ]
Subtotal (95% CI)
21

Total (95% CI)
29

-2
-1
Favours No SLT

Favours SLT
101
Analysis 1.7. Comparison 1 SLT versus no SLT, Outcome 7 Expressive language: general.
Review:

Outcome: 7 Expressive language: general
Study or subgroup
SLT
No SLT
Mean Difference
Weight
IV,Fixed,95% CI
Mean Difference
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Katz 1997i
10
62.3 (22.3)
15
58.1 (19.1)
15.4 %
4.20 [ -12.67, 21.07 ]
Katz 1997ii
11
62.3 (22.3)
19
50.6 (24.5)
14.8 %
11.70 [ -5.48, 28.88 ]
Wertz 1986i
31
56.48 (18.29)
17
52.8 (19.48)
34.3 %
3.68 [ -7.60, 14.96 ]
Wertz 1986ii
37
57.41 (20.1)
18
52.8 (19.48)
35.5 %
4.61 [ -6.48, 15.70 ]
Total (95% CI)
89
100.0 %
5.28 [ -1.33, 11.89 ]
1 PICA Verbal subtest
69

Test for subgroup differences: Not applicable
-50
-25
Favours No SLT

25
50
Favours SLT
102
Analysis 1.8. Comparison 1 SLT versus no SLT, Outcome 8 Expressive language: written.
Review:

Outcome: 8 Expressive language: written
Study or subgroup
SLT
No SLT
Mean Difference
Weight
IV,Fixed,95% CI
Mean Difference
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Katz 1997i
10
61.9 (14.8)
15
60.4 (19)
52.5 %
1.50 [ -11.79, 14.79 ]
Katz 1997ii
11
61.9 (14.8)
19
55.4 (24.2)
47.5 %
6.50 [ -7.46, 20.46 ]
100.0 %
3.88 [ -5.75, 13.50 ]
1 PICA Copying subtest
Subtotal (95% CI)
21
34

2 PICA Writing subtest
Katz 1997i
10
66.9 (23.2)
15
59.2 (23.1)
48.0 %
7.70 [ -10.83, 26.23 ]
Katz 1997ii
11
66.9 (23.2)
19
57.9 (25.3)
52.0 %
9.00 [ -8.82, 26.82 ]
100.0 %
8.38 [ -4.47, 21.22 ]
Subtotal (95% CI)
21
34

3 PICA Graphic
Wertz 1986i
31
72.64 (16.6)
17
68.57 (22.69)
51.4 %
4.07 [ -8.20, 16.34 ]
Wertz 1986ii
37
74.86 (21.74)
18
68.57 (22.69)
48.6 %
6.29 [ -6.32, 18.90 ]
100.0 %
5.15 [ -3.64, 13.94 ]
Subtotal (95% CI)
68
35

-50
-25
Favours No SLT

25
50
Favours SLT
103
Analysis 1.9. Comparison 1 SLT versus no SLT, Outcome 9 Expressive language: repetition.
Review:

Outcome: 9 Expressive language: repetition
Study or subgroup
SLT
No SLT
Mean Difference
Weight
IV,Fixed,95% CI
Mean Difference
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Katz 1997i
10
7.3 (2.9)
15
6.7 (3.4)
46.0 %
0.60 [ -1.89, 3.09 ]
Katz 1997ii
11
7.3 (2.9)
19
6.1 (3.4)
54.0 %
1.20 [ -1.10, 3.50 ]
100.0 %
0.92 [ -0.76, 2.61 ]
1 WAB Repetition subtest
Subtotal (95% CI)
21
34

-4
-2
Favours No SLT

Favours SLT
104
Analysis 1.10. Comparison 1 SLT versus no SLT, Outcome 10 Severity of impairment: Aphasia Battery
Score (+ PICA).
Review:

Outcome: 10 Severity of impairment: Aphasia Battery Score (+ PICA)
Study or subgroup
SLT
No SLT
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Jufeng 2005i
30
66.93 (25.62)
15
62.4 (27.46)
17.9 %
0.17 [ -0.45, 0.79 ]
Jufeng 2005ii
24
57.8 (34.81)
15
62.4 (27.46)
16.6 %
-0.14 [ -0.79, 0.51 ]
34.5 %
0.02 [ -0.43, 0.47 ]
1 Aphasia Quotient (CRRCAE)
Subtotal (95% CI)
54
30

2 Porch Index of Communicative Ability
Katz 1997i
11
66.4 (19.4)
15
61.3 (17.4)
11.3 %
0.27 [ -0.51, 1.05 ]
Katz 1997ii
10
66.4 (19.4)
19
56.3 (20.9)
11.4 %
0.48 [ -0.30, 1.26 ]
Wertz 1986i
38
65.65 (24.64)
18
61.66 (21.21)
21.9 %
0.17 [ -0.40, 0.73 ]
Wertz 1986ii
37
67.19 (24.64)
17
61.66 (21.21)
20.8 %
0.23 [ -0.35, 0.81 ]
69
65.5 %
0.26 [ -0.07, 0.58 ]
99
100.0 %
0.18 [ -0.09, 0.44 ]
Subtotal (95% CI)
96

Total (95% CI)
150

-2
-1
Favours No SLT

Favours SLT
105
Analysis 1.11. Comparison 1 SLT versus no SLT, Outcome 11 Severity of impairment: Aphasia Battery
Score (3-month follow up).
Review:

Outcome: 11 Severity of impairment: Aphasia Battery Score (3-month follow up)
Study or subgroup
SLT
No SLT
Mean(SD)
Mean Difference
Mean(SD)
Weight
IV,Random,95% CI
Mean Difference
IV,Random,95% CI
1 Aphasia Quotient (CRRCAE) 3-month follow up

Jufeng 2005i
30
71.16 (33.79)
15
33.66 (31.3)
49.8 %
37.50 [ 17.57, 57.43 ]
Jufeng 2005ii
24
37.75 (28.61)
15
33.66 (31.3)
50.2 %
4.09 [ -15.45, 23.63 ]
100.0 %
20.74 [ -12.01, 53.48 ]
Subtotal (95% CI)
54
30
Heterogeneity: Tau2 = 456.72; Chi2 = 5.50, df = 1 (P = 0.02); I2 =82%

-100
-50
50
Favours No SLT
100
Favours SLT
Analysis 1.12. Comparison 1 SLT versus no SLT, Outcome 12 Psychosocial: MAACL.

Review:

Outcome: 12 Psychosocial: MAACL
Study or subgroup
SLT
No SLT
Mean Difference
Mean(SD)
Mean(SD)
75
3 (3.2)
62
2.6 (2.6)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Anxiety Scale (MAACL)

Lincoln 1984a
Subtotal (95% CI)
75
62
100.0 %
0.40 [ -0.57, 1.37 ]
100.0 %
0.40 [ -0.57, 1.37 ]
100.0 %
0.70 [ -1.38, 2.78 ]
100.0 %
0.70 [ -1.38, 2.78 ]

2 Depression Scale (MAACL)
Lincoln 1984a
Subtotal (95% CI)
75
75
6.9 (6.6)
62
6.2 (5.8)
62

-4
-2
Favours SLT
Favours No SLT
(Continued . . . )

106
Study or subgroup
SLT
No SLT
Mean Difference
Mean(SD)
Mean(SD)
75
2.7 (2.7)
62
2.8 (2.1)
Weight
IV,Fixed,95% CI
(. . . Continued)
Mean Difference
IV,Fixed,95% CI
3 Hostility Scale (MAACL)

Lincoln 1984a
Subtotal (95% CI)
75
62
100.0 %
-0.10 [ -0.90, 0.70 ]
100.0 %
-0.10 [ -0.90, 0.70 ]

-4
-2
Favours SLT
Favours No SLT
Analysis 1.13. Comparison 1 SLT versus no SLT, Outcome 13 Number of drop-outs (any reason).
Review:

Outcome: 13 Number of drop-outs (any reason)
Study or subgroup
SLT
No SLT
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
1/9
0/10
0.6 %
3.71 [ 0.13, 103.11 ]
Katz 1997i
0/10
6/21
5.7 %
0.11 [ 0.01, 2.24 ]
Katz 1997ii
0/11
2/21
2.3 %
0.34 [ 0.01, 7.70 ]
Lincoln 1984a
76/163
90/164
65.8 %
0.72 [ 0.46, 1.11 ]
MacKay 1988
0/48
1/48
2.0 %
0.33 [ 0.01, 8.22 ]
Smania 2006
12/20
12/21
6.4 %
1.13 [ 0.32, 3.90 ]
Smith 1981i
10/16
0/9
0.3 %
30.69 [ 1.52, 621.02 ]
Smith 1981ii
6/14
0/8
0.5 %
13.00 [ 0.63, 268.93 ]
Wertz 1986i
9/38
5/20
6.9 %
0.93 [ 0.26, 3.28 ]
Wertz 1986ii
7/43
6/20
9.4 %
0.45 [ 0.13, 1.59 ]
Total (95% CI)
372
342
100.0 %
0.86 [ 0.61, 1.20 ]
Doesborgh 2004b
Weight
Odds Ratio
M-H,Fixed,95% CI
Total events: 121 (SLT), 122 (No SLT)

Heterogeneity: Chi2 = 13.56, df = 9 (P = 0.14); I2 =34%
0.02
0.1
Favours SLT
10
50
Favours No SLT

107
Analysis 2.1. Comparison 2 SLT versus social support and stimulation, Outcome 1 Functional
communication.
Review:
Comparison: 2 SLT versus social support and stimulation

Study or subgroup
SLT
N
Social Support
Mean Difference
Mean(SD)
Mean(SD)
67 (20.3)
48
69.2 (22.4)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI

David 1982
Subtotal (95% CI)
48
48
48
100.0 %
-2.20 [ -10.75, 6.35 ]
100.0 %
-2.20 [ -10.75, 6.35 ]
100.0 %
1.40 [ -8.01, 10.81 ]
100.0 %
1.40 [ -8.01, 10.81 ]
100.0 %
1.30 [ -8.07, 10.67 ]
100.0 %
1.30 [ -8.07, 10.67 ]

2 FCP (3-month follow up)
David 1982
Subtotal (95% CI)
37
70.4 (19.1)
37
36
69 (21.8)
36

3 FCP (6-month follow up)
David 1982
Subtotal (95% CI)
37
69.3 (19.6)
37
36
68 (21.2)
36

-20
-10
Favours Social Support

10
20
Favours SLT
108
Analysis 2.2. Comparison 2 SLT versus social support and stimulation, Outcome 2 Receptive language:
auditory comprehension.
Review:

Study or subgroup
SLT
N
Social Support
Mean(SD)
Mean Difference
Mean(SD)
66 (4)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Sentence Comprehension Test (PCB)

Rochon 2005
Subtotal (95% CI)
72 (16)
100.0 %
6.00 [ -12.94, 24.94 ]
100.0 %
6.00 [ -12.94, 24.94 ]
100.0 %
8.00 [ -10.94, 26.94 ]
100.0 %
8.00 [ -10.94, 26.94 ]
100.0 %
-3.83 [ -18.95, 11.29 ]
100.0 %
-3.83 [ -18.95, 11.29 ]

2 Picture Comprehension Test (PCB)
Rochon 2005
Subtotal (95% CI)
78 (16)
70 (4)

3 Token Test
Lincoln 1982iii
Subtotal (95% CI)
12
59 (13.93)
12
62.83 (16.13)

-50
-25

25
50
Favours SLT
109
Analysis 2.3. Comparison 2 SLT versus social support and stimulation, Outcome 3 Receptive language:
other.
Review:

Study or subgroup
SLT
Social Support
Mean Difference
Mean(SD)
Mean(SD)
12
12.14 (0.8)
13.01 (0.87)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 PICA Gestural subtest

Lincoln 1982iii
Subtotal (95% CI)
12
100.0 %
-0.87 [ -1.70, -0.04 ]
100.0 %
-0.87 [ -1.70, -0.04 ]

-2
-1
Favours SLT
Analysis 2.4. Comparison 2 SLT versus social support and stimulation, Outcome 4 Expressive language:
single words.
Review:

Outcome: 4 Expressive language: single words
Study or subgroup
SLT
Social Support
Mean Difference
Mean(SD)
Mean(SD)
12
9.83 (6.32)
16.83 (3.76)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Object Naming Test (ONT)

Lincoln 1982iii
Subtotal (95% CI)
12
100.0 %
-7.00 [ -11.67, -2.33 ]
100.0 %
-7.00 [ -11.67, -2.33 ]
100.0 %
-14.00 [ -20.35, -7.65 ]

2 Word fluency
Lincoln 1982iii
Subtotal (95% CI)
12
10 (5.98)
12
24 (6.72)
100.0 % -14.00 [ -20.35, -7.65 ]

Test for subgroup differences: Chi2 = 3.03, df = 1 (P = 0.08), I2 =67%
-20
-10

10
20
Favours SLT
110
sentences.
Review:

Outcome: 5 Expressive language: sentences
Study or subgroup
SLT
Social Support
Mean Difference
Mean(SD)
Mean(SD)
7 (2)
5 (3)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Caplan % Hanna Test: total

Rochon 2005
Subtotal (95% CI)
100.0 %
2.00 [ -2.73, 6.73 ]
100.0 %
2.00 [ -2.73, 6.73 ]
100.0 %
3.00 [ 0.63, 5.37 ]
100.0 %
3.00 [ 0.63, 5.37 ]
100.0 %
-1.00 [ -5.31, 3.31 ]
100.0 %
-1.00 [ -5.31, 3.31 ]

2 Caplan % Hanna Test: treated
Rochon 2005
Subtotal (95% CI)
6 (2)
3 (0.5)

3 Caplan % Hanna Test: untreated
Rochon 2005
Subtotal (95% CI)
1 (1)
2 (3)

-10
-5

10
Favours SLT
111
picture description.
Review:

Outcome: 6 Expressive language: picture description
Study or subgroup
SLT
Social Support
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Lincoln 1982iii
12
33.67 (22)
30.67 (7.87)
81.5 %
0.15 [ -0.83, 1.13 ]
Rochon 2005
34.67 (4.04)
27 (11.31)
18.5 %
0.76 [ -1.30, 2.83 ]
100.0 %
0.26 [ -0.62, 1.15 ]
100.0 %
0.45 [ -1.44, 2.33 ]
100.0 %
0.45 [ -1.44, 2.33 ]
100.0 %
0.41 [ -1.46, 2.28 ]
100.0 %
0.41 [ -1.46, 2.28 ]
1 Picture description
Subtotal (95% CI)
15

2 Picture description with structure modelling: treated items
Rochon 2005
Subtotal (95% CI)
16 (2.65)
14 (4.24)

3 Picture description with structure modelling: untreated items
Rochon 2005
Subtotal (95% CI)
18.67 (3.06)
16 (7.07)

-4
-2

Favours SLT
112
overall spoken.
Review:

Outcome: 7 Expressive language: overall spoken
Study or subgroup
SLT
Social Support
Mean Difference
Mean(SD)
Mean(SD)
12
10.52 (1.2)
12.08 (0.74)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 PICA verbal subtest

Lincoln 1982iii
Subtotal (95% CI)
12
100.0 %
-1.56 [ -2.46, -0.66 ]
100.0 %
-1.56 [ -2.46, -0.66 ]

-2
-1
Favours SLT
written.
Review:

Study or subgroup
SLT
Social Support
Mean Difference
Mean(SD)
Mean(SD)
12
7.52 (1.34)
8.91 (1)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 PICA graphic subtests

Lincoln 1982iii
Subtotal (95% CI)
12
100.0 %
-1.39 [ -2.49, -0.29 ]
100.0 %
-1.39 [ -2.49, -0.29 ]

-4
-2

Favours SLT
113
Analysis 2.9. Comparison 2 SLT versus social support and stimulation, Outcome 9 Severity of impairment:
Aphasia Battery Score.
Review:

Outcome: 9 Severity of impairment: Aphasia Battery Score
Study or subgroup
SLT
Social Support
Mean Difference
Mean(SD)
Mean(SD)
12
10.3 (1.01)
11.43 (0.67)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 PICA
Lincoln 1982iii
Subtotal (95% CI)
12
100.0 %
-1.13 [ -1.91, -0.35 ]
100.0 %
-1.13 [ -1.91, -0.35 ]

-2
-1
Favours SLT
Analysis 2.10. Comparison 2 SLT versus social support and stimulation, Outcome 10 Number of drop-outs
for any reason.
Review:

Outcome: 10 Number of drop-outs for any reason
Study or subgroup
SLT
Social Support
n/N
n/N
Odds Ratio
Weight
David 1982
34/71
48/84
73.0 %
0.69 [ 0.37, 1.30 ]
Elman 1999
3/14
4/14
9.9 %
0.68 [ 0.12, 3.83 ]
Shewan 1984ii
6/28
3/13
11.9 %
0.91 [ 0.19, 4.39 ]
Shewan 1984iii
1/24
3/12
5.2 %
0.13 [ 0.01, 1.42 ]
Total (95% CI)
137
123
100.0 %
0.65 [ 0.38, 1.12 ]
M-H,Random,95% CI
Odds Ratio
M-H,Random,95% CI
Total events: 44 (SLT), 58 (Social Support)

Heterogeneity: Tau2 = 0.0; Chi2 = 1.95, df = 3 (P = 0.58); I2 =0.0%
0.005
0.1
Favours SLT
10
200

114
communication.
Review:
Comparison: 3 Functional SLT (SLTA) versus conventional SLT (SLTB)

Study or subgroup
Functional SLT
Conventional SLT
Mean Difference
Mean(SD)
Mean(SD)
0.5 (5)
9.8 (5.1)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 CADL (change from baseline)

Hinckley 2001
Subtotal (95% CI)
100.0 %
-9.30 [ -15.01, -3.59 ]
100.0 % -9.30 [ -15.01, -3.59 ]

2 CETI
Hinckley 2001
Subtotal (95% CI)
9.8 (4.3)
13.7 (4.1)
100.0 %
-3.90 [ -8.65, 0.85 ]
100.0 %
-3.90 [ -8.65, 0.85 ]

-20
-10
Favours Conventional SLT

10
20
Favours Functional SLT
115
communication: catalogue ordering.
Review:

Outcome: 2 Functional communication: catalogue ordering
Study or subgroup
Functional SLT
N
Conventional SLT
Mean Difference
Mean(SD)
Mean(SD)
32.3 (15)
-0.5 (14.4)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Telephone order (change from baseline)

Hinckley 2001
Subtotal (95% CI)
100.0 %
32.80 [ 16.16, 49.44 ]
100.0 % 32.80 [ 16.16, 49.44 ]

2 Telephone order (+ concurrent task) (change from baseline)
Hinckley 2001
Subtotal (95% CI)
24.2 (15.5)
100.0 %
16.90 [ 1.31, 32.49 ]
100.0 %
16.90 [ 1.31, 32.49 ]
100.0 %
-5.00 [ -19.81, 9.81 ]
7.3 (11.8)

3 Written order (change from baseline)
Hinckley 2001
Subtotal (95% CI)
6.8 (14.5)
11.8 (11.5)
100.0 % -5.00 [ -19.81, 9.81 ]

4 Written order (+ concurrent task) (change from baseline)
Hinckley 2001
Subtotal (95% CI)
24.3 (20.6)
14.5 (14)
100.0 %
9.80 [ -10.13, 29.73 ]
100.0 % 9.80 [ -10.13, 29.73 ]

-100
-50

50
100
116
Analysis 3.3. Comparison 3 Functional SLT (SLTA) versus conventional SLT (SLTB), Outcome 3 Expressive
language: spoken.
Review:

Outcome: 3 Expressive language: spoken
Study or subgroup
Functional SLT
N
Conventional SLT
Mean(SD)
Mean Difference
Mean(SD)
7.5 (10.1)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Oral naming: PALPA (change from baseline)

Hinckley 2001
Subtotal (95% CI)
13.5 (14.6)
100.0 %
6.00 [ -8.21, 20.21 ]
100.0 % 6.00 [ -8.21, 20.21 ]

-100
-50
50
100
Analysis 3.4. Comparison 3 Functional SLT (SLTA) versus conventional SLT (SLTB), Outcome 4 Expressive
language: written.
Review:

Study or subgroup
Functional SLT
N
Conventional SLT
Mean(SD)
Mean Difference
Mean(SD)
9.7 (8.4)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Written naming: PALPA (change from baseline)

Hinckley 2001
Subtotal (95% CI)
7.5 (7.6)
100.0 %
-2.20 [ -11.26, 6.86 ]
100.0 % -2.20 [ -11.26, 6.86 ]

-100
-50

50
100
Favours Funcational SLT
117
Analysis 4.1. Comparison 4 Intensive SLT (SLTA) versus conventional SLT (SLTB), Outcome 1 Receptive
language: auditory comprehension (change from baseline).
Review:
Comparison: 4 Intensive SLT (SLTA) versus conventional SLT (SLTB)

Outcome: 1 Receptive language: auditory comprehension (change from baseline)
Study or subgroup
Intensive
Conventional
Mean Difference
Mean(SD)
Mean(SD)
12.6 (15.2)
2.3 (3.8)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 AAT Comprehension subtest

Denes 1996
Subtotal (95% CI)
100.0 %
10.30 [ -0.52, 21.12 ]
100.0 % 10.30 [ -0.52, 21.12 ]

2 Token Test
Denes 1996
Subtotal (95% CI)
11.4 (11.6)
5.2 (7.8)
100.0 %
6.20 [ -3.32, 15.72 ]
100.0 %
6.20 [ -3.32, 15.72 ]

-20
-10

10
20
Favours Intensive SLT
118
Analysis 4.2. Comparison 4 Intensive SLT (SLTA) versus conventional SLT (SLTB), Outcome 2 Expressive
language: spoken (change from baseline scores).
Review:

Outcome: 2 Expressive language: spoken (change from baseline scores)
Study or subgroup
Intensive
Conventional
Mean Difference
Mean(SD)
Mean(SD)
10.2 (9.9)
4.5 (4.2)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Naming subtest (AAT)

Denes 1996
Subtotal (95% CI)
100.0 %
5.70 [ -1.69, 13.09 ]
100.0 %
5.70 [ -1.69, 13.09 ]
100.0 %
2.80 [ -3.86, 9.46 ]
100.0 %
2.80 [ -3.86, 9.46 ]

2 Repetition subtest (AAT)
Denes 1996
Subtotal (95% CI)
8.9 (7.7)
6.1 (6.1)

-20
-10
10
20
Analysis 4.3. Comparison 4 Intensive SLT (SLTA) versus conventional SLT (SLTB), Outcome 3 Written
language: (change from baseline scores).
Review:

Outcome: 3 Written language: (change from baseline scores)
Study or subgroup
Intensive
Conventional
Mean Difference
Mean(SD)
Mean(SD)
11 (9.8)
2.1 (3.1)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Written subtest (AAT)

Denes 1996
Subtotal (95% CI)
100.0 %
8.90 [ 1.81, 15.99 ]
100.0 %
8.90 [ 1.81, 15.99 ]

-20
-10

10
20
119
Analysis 4.4. Comparison 4 Intensive SLT (SLTA) versus conventional SLT (SLTB), Outcome 4 Severity of
impairment: Aphasia Battery Score.
Review:

Study or subgroup
Intensive
Conventional
Mean Difference
Weight
IV,Fixed,95% CI
Mean Difference
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Bakheit 2007
35
70.3 (26.9)
38
66.2 (26.2)
69.9 %
4.10 [ -8.10, 16.30 ]
ORLA 2006
57.58 (14.82)
60.48 (19.35)
30.1 %
-2.90 [ -21.50, 15.70 ]
100.0 %
2.00 [ -8.21, 12.20 ]
100.0 %
5.70 [ -0.76, 12.16 ]
100.0 %
5.70 [ -0.76, 12.16 ]
100.0 %
1.90 [ -10.53, 14.33 ]
1 Aphasia Quotient (WAB)
Subtotal (95% CI)
41
45

2 AAT profile (change from baseline)
Denes 1996
Subtotal (95% CI)
10 (8.6)
4.3 (3.8)

3 Aphasia Quotient (WAB) 3-month follow up
Bakheit 2007
Subtotal (95% CI)
31
69.9 (25.2)
31
35
68 (26.3)
100.0 % 1.90 [ -10.53, 14.33 ]
35

-50
-25

25
50
120
Analysis 4.5. Comparison 4 Intensive SLT (SLTA) versus conventional SLT (SLTB), Outcome 5 Number of
drop-outs for any reason.
Review:

Study or subgroup
Intensive
Conventional
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Bakheit 2007
20/51
11/46
74.6 %
2.05 [ 0.85, 4.95 ]
Smith 1981iii
10/16
6/14
25.4 %
2.22 [ 0.51, 9.61 ]
67
60
100.0 %
2.10 [ 0.99, 4.46 ]
Total (95% CI)
Weight
Odds Ratio
M-H,Fixed,95% CI
Total events: 30 (Intensive), 17 (Conventional)

0.01
0.1
10
100
Analysis 5.1. Comparison 5 Volunteer-facilitated SLT (SLTA) versus professional SLT (SLTB), Outcome 1
Functional communication.
Review:
Comparison: 5 Volunteer-facilitated SLT (SLTA) versus professional SLT (SLTB)

Study or subgroup
Volunteer Facilitated SLT

N
Professional SLT
Mean(SD)
Mean Difference
Mean(SD)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 CADL
Wertz 1986iii
Subtotal (95% CI)
37 105.38 (31.67)
37
31 103.74 (24.42)
100.0 %
31
1.64 [ -11.70, 14.98 ]
100.0 % 1.64 [ -11.70, 14.98 ]

Wertz 1986iii
Subtotal (95% CI)
37
62.05 (21.83)
37
100.0 %
31 59.35 (19.62)
2.70 [ -7.16, 12.56 ]
100.0 % 2.70 [ -7.16, 12.56 ]
31

-100
-50
Favours Professional SLT

50
100
Favours Volunteer SLT
121
Receptive language: auditory comprehension.
Review:

Study or subgroup
Professional SLT
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Meinzer 2007
10
23.2 (13.25)
10
21.1 (17.84)
22.8 %
0.13 [ -0.75, 1.01 ]
Wertz 1986iii
37 119.89 (45.06)
31 118.39 (41.95)
77.2 %
0.03 [ -0.44, 0.51 ]
100.0 %
0.06 [ -0.36, 0.47 ]
100.0 %
-0.37 [ -1.25, 0.52 ]
100.0 %
-0.37 [ -1.25, 0.52 ]
1 Token Test
Subtotal (95% CI)
47
41

2 AAT subtest
Meinzer 2007
Subtotal (95% CI)
10
10
90 (15.78)
10
95.7 (13.92)
10

-4
-2

Favours Vol Facilitated
122
Receptive language: reading comprehension.
Review:

Study or subgroup
Professional SLT
Mean(SD)
Mean Difference
Mean(SD)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Reading Comprehension Battery for Aphasia

Wertz 1986iii
37 77.24 (20.79)
Subtotal (95% CI)
100.0 %
31 76.9 (16.97)
37
31
0.34 [ -8.64, 9.32 ]
100.0 % 0.34 [ -8.64, 9.32 ]

-100
-50
Favours Professional
50
100
Favours Volunteer
Receptive language: other.
Review:

Study or subgroup Volunteer Facilitated SLT

N
Professional SLT
Mean(SD)
Mean Difference
Mean(SD)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 PICA gestural subtest

Wertz 1986iii
Total (95% CI)
37 62.78 (25.67)
37
31 65.32 (19.03)
100.0 %
-2.54 [ -13.18, 8.10 ]
100.0 % -2.54 [ -13.18, 8.10 ]
31

-20
-10
Favours Professional

10
20
Favours Volunteer
123
Expressive language: spoken.
Review:

Study or subgroup
Professional SLT
Mean(SD)
10
87.5 (19.65)
Mean Difference
Mean(SD)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 AAT naming subtest

Meinzer 2007
Subtotal (95% CI)
10 79.1 (27.77)
10
100.0 %
10
8.40 [ -12.68, 29.48 ]
100.0 % 8.40 [ -12.68, 29.48 ]

Wertz 1986iii
37 57.41 (20.01)
Subtotal (95% CI)
100.0 %
31 56.48 (18.29)
37
31
0.93 [ -8.18, 10.04 ]
100.0 % 0.93 [ -8.18, 10.04 ]

-100
-50
50
100
Expressive language: repetition.
Review:

Study or subgroup

N
Professional SLT
Mean(SD)
Mean Difference
Mean(SD)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 AAT Repetition subtest

Meinzer 2007
Subtotal (95% CI)
10 129 (13.53)
10
10 115.5 (16.68)
100.0 %
13.50 [ 0.19, 26.81 ]
100.0 % 13.50 [ 0.19, 26.81 ]
10

-50
-25

25
50
124
Expressive language: written.
Review:

Study or subgroup
Professional SLT
Mean Difference
Mean(SD)
Mean(SD)
10
58.1 (24.4)
10
48.6 (23.8)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 AAT written language subtest

Meinzer 2007
Subtotal (95% CI)
10
100.0 %
10
9.50 [ -11.63, 30.63 ]
100.0 % 9.50 [ -11.63, 30.63 ]

2 PICA graphic subtests
Wertz 1986iii
Subtotal (95% CI)
37 74.86 (21.74)
37
31 72.64 (16.6)
100.0 %
31
2.22 [ -6.90, 11.34 ]
100.0 % 2.22 [ -6.90, 11.34 ]

-100
-50

50
100
125
Severity of impairment: Aphasia Battery Score.
Review:

Study or subgroup
Professional SLT
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Meikle 1979
15
62.2 (27.12)
16
72 (22.9)
24.3 %
-0.38 [ -1.09, 0.33 ]
Wertz 1986iii
37 67.19 (24.64)
38 65.65 (18.85)
60.1 %
0.07 [ -0.38, 0.52 ]
84.5 %
-0.06 [ -0.44, 0.32 ]
15.5 %
-0.45 [ -1.34, 0.44 ]
1 PICA
Subtotal (95% CI)
52
54

2 AAT
Meinzer 2007
Subtotal (95% CI)
10
52.96 (5.49)
10 55.54 (5.44)
10
10
15.5 %
-0.45 [ -1.34, 0.44 ]
62
64
100.0 %
-0.12 [ -0.47, 0.23 ]

Total (95% CI)

-2
-1

126
Number of drop-outs for any reason.
Review:

Study or subgroup
Professional SLT
n/N
n/N
21/59
13/35
58.9 %
0.94 [ 0.39, 2.23 ]
Meikle 1979
0/16
2/15
4.6 %
0.16 [ 0.01, 3.71 ]
Wertz 1986iii
9/38
7/43
36.6 %
1.60 [ 0.53, 4.81 ]
Total (95% CI)
113
93
100.0 %
1.05 [ 0.54, 2.04 ]
Leal 1993
Odds Ratio
Weight
M-H,Random,95% CI
Odds Ratio
M-H,Random,95% CI
Total events: 30 (Volunteer Facilitated SLT), 22 (Professional SLT)

Heterogeneity: Tau2 = 0.0; Chi2 = 2.00, df = 2 (P = 0.37); I2 =0.0%
0.01
0.1

10
100
127
Analysis 6.1. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 1 Receptive language:
auditory comprehension.
Review:
Comparison: 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB)

Study or subgroup
Group SLT
1-to-1 SLT
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Pulvermuller 2001
10
53 (7.24)
54 (8.16)
33.3 %
-0.12 [ -1.09, 0.84 ]
Wertz 1981
16
40.19 (13.93)
18
33.89 (13.93)
66.7 %
0.44 [ -0.24, 1.12 ]
100.0 %
0.25 [ -0.30, 0.81 ]
100.0 %
0.47 [ -0.51, 1.45 ]
100.0 %
0.47 [ -0.51, 1.45 ]
1 Token Test
Subtotal (95% CI)
26
25

2 AAT comprehension subtest
Pulvermuller 2001
10
Subtotal (95% CI)
10
60.3 (9.29)
55.29 (11.19)

-4
-2
Favours 1-to-1 SLT
Favours Group SLT
Analysis 6.2. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 2 Receptive language:
other.
Review:

Study or subgroup
Group SLT
1-to-1 SLT
Mean Difference
Mean(SD)
Mean(SD)
16
72 (25.67)
18
70.22 (25.67)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI

Wertz 1981
Subtotal (95% CI)
16
100.0 %
1.78 [ -15.51, 19.07 ]
100.0 % 1.78 [ -15.51, 19.07 ]
18

-50
-25
Favours 1-to-1 SLT

25
50
Favours Group SLT
128
Analysis 6.3. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 3 Expressive language:
spoken.
Review:

Study or subgroup
Group SLT
1-to-1 SLT
Mean(SD)
Mean(SD)
Pulvermuller 2001
10
56.5 (6.35)
54.14 (7.01)
Subtotal (95% CI)
10
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
1 AAT naming subtest
100.0 %
0.34 [ -0.64, 1.31 ]
100.0 %
0.34 [ -0.64, 1.31 ]
100.0 %
0.04 [ -0.63, 0.71 ]
100.0 %
0.04 [ -0.63, 0.71 ]

Wertz 1981
Subtotal (95% CI)
16
66.25 (20.01)
16
18
65.44 (20.01)
18

-1
-0.5
Favours 1-to-1 SLT

0.5
Favours Group SLT
129
repetition.
Review:

Study or subgroup
Group SLT
1-to-1 SLT
Mean Difference
Mean(SD)
Mean(SD)
10
52.5 (4.22)
53.14 (8.23)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 AAT repetition subtest

Pulvermuller 2001
Total (95% CI)
10
100.0 %
-0.64 [ -7.27, 5.99 ]
100.0 %
-0.64 [ -7.27, 5.99 ]

-10
-5
Favours 1-to-1 SLT
10
Favours Group SLT
written.
Review:

Study or subgroup
Group SLT
1-to-1 SLT
Mean Difference
Mean(SD)
Mean(SD)
16
72.25 (21.74)
18
78.28 (21.74)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 PICA graphic
Wertz 1981
Subtotal (95% CI)
16
100.0 %
-6.03 [ -20.67, 8.61 ]
100.0 % -6.03 [ -20.67, 8.61 ]
18

-50
-25
Favours 1-to-1 SLT

25
50
Favours Group SLT
130
Analysis 6.6. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 6 Severity of
impairment: Aphasia Battery Score.
Review:

Study or subgroup
Group SLT
1-to-1 SLT
Mean(SD)
Mean(SD)
30
66.93 (25.62)
24
57.8 (34.81)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
1 Aphasia Quotient CRRCAE

Jufeng 2005iii
Subtotal (95% CI)
30
51.2 %
0.30 [ -0.24, 0.84 ]
51.2 %
0.30 [ -0.24, 0.84 ]
32.9 %
-0.06 [ -0.73, 0.61 ]
32.9 %
-0.06 [ -0.73, 0.61 ]
15.9 %
0.23 [ -0.74, 1.20 ]
15.9 %
0.23 [ -0.74, 1.20 ]
49
100.0 %
0.17 [ -0.22, 0.56 ]
24

2 PICA overall
Wertz 1981
Subtotal (95% CI)
16
70.69 (24.64)
16
18
72.17 (24.64)
18

3 AAT overall
Pulvermuller 2001
10
Subtotal (95% CI)
10
55.58 (5.88)
54.14 (6.3)

Total (95% CI)
56

-2
-1
Favours One-to-one SLT

Favours Group SLT
131
Analysis 6.7. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 7 Severity of
impairment: Aphasia Battery Score (3-month follow up).
Review:

Outcome: 7 Severity of impairment: Aphasia Battery Score (3-month follow up)
Study or subgroup
Group SLT
1-to-1 SLT
Mean(SD)
Mean Difference
Mean(SD)
24
37.75 (28.61)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Aphasia Quotient CRRCAE (3-month follow up)

Jufeng 2005iii
Subtotal (95% CI)
30
71.16 (33.79)
30
100.0 %
24
33.41 [ 16.76, 50.06 ]
100.0 % 33.41 [ 16.76, 50.06 ]

-50
-25
Favours One-to-one SLT
25
50
Favours Group SLT
Analysis 6.8. Comparison 6 Group SLT (SLTA) versus 1-to-1 SLT (SLTB), Outcome 8 Number of drop-outs
for any reason.
Review:

Study or subgroup
Wertz 1981
Total (95% CI)
Group SLT
1-to-1 SLT
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
17/35
16/32
100.0 %
0.94 [ 0.36, 2.46 ]
35
32
100.0 %
0.94 [ 0.36, 2.46 ]
M-H,Fixed,95% CI
Total events: 17 (Group SLT), 16 (1-to-1 SLT)

0.01
0.1
Favours Group
10
100
Favours 1-to-1 SLT

132
Analysis 7.1. Comparison 7 Task-specific SLT (SLTA) versus conventional SLT (SLTB), Outcome 1
Functional communication.
Review:
Comparison: 7 Task-specific SLT (SLTA) versus conventional SLT (SLTB)

Study or subgroup
Task Specific SLT
Conventional SLT
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
10
2.9 (1.8)
11
3.4 (3.7)
68.4 %
-0.16 [ -1.02, 0.70 ]
3.86 (1.41)
4.8 (2.37)
31.6 %
-0.44 [ -1.70, 0.83 ]
Subtotal (95% CI)
15
100.0 %
-0.25 [ -0.96, 0.46 ]
1 Functional expression
Prins 1989
16

-2
-1

Favours Task Specific SLT
133
Receptive language: auditory comprehension - word.
Review:

Outcome: 2 Receptive language: auditory comprehension - word
Study or subgroup
Task Specific SLT

N
Conventional SLT
Mean(SD)

Mean(SD)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
1 Word comprehension (BDAE subtest)

Lincoln 1984b
Prins 1989
Subtotal (95% CI)
6 39.67 (10.89)
10
27.6 (8.5)
16
6 38.17 (10.72)
11
28.4 (6.6)
17
36.4 %
0.13 [ -1.01, 1.26 ]
63.6 %
-0.10 [ -0.96, 0.76 ]
100.0 %
-0.02 [ -0.70, 0.67 ]
100.0 %
-0.22 [ -1.08, 0.64 ]
100.0 %
-0.22 [ -1.08, 0.64 ]
100.0 %
0.13 [ -1.01, 1.26 ]
100.0 %
0.13 [ -1.01, 1.26 ]

2 Identify body part (BDAE subtest)
Prins 1989
Subtotal (95% CI)
10
15.2 (4.3)
10
11
16.1 (3.5)
11

3 Peabody PVT
Lincoln 1984b
Subtotal (95% CI)
6 39.67 (10.89)
6 38.17 (10.72)

-2
-1

134
Receptive language: other auditory comprehension.
Review:

Outcome: 3 Receptive language: other auditory comprehension
Study or subgroup
Task Specific SLT
Conventional SLT
Mean(SD)
Mean(SD)
10
15.3 (5.9)
11
18.4 (5.7)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
1 Sentence comprehension
Prins 1989
Subtotal (95% CI)
10
11
100.0 %
-0.51 [ -1.39, 0.36 ]
100.0 %
-0.51 [ -1.39, 0.36 ]
100.0 %
0.47 [ -0.51, 1.45 ]
100.0 %
0.47 [ -0.51, 1.45 ]

2 AAT comprehension subtest
Pulvermuller 2001
10
Subtotal (95% CI)
10
60.3 (9.29)
7 55.29 (11.19)

3 Token Test
Lincoln 1982i
6 67.83 (14.82)
6 60.33 (17.24)
16.1 %
0.43 [ -0.72, 1.58 ]
Lincoln 1982ii
62.5 (25.36)
6 66.33 (14.47)
16.5 %
-0.17 [ -1.31, 0.96 ]
Lincoln 1984b
6 36.83 (21.24)
6 27.67 (17.61)
16.0 %
0.43 [ -0.72, 1.58 ]
Prins 1989
10
5.1 (3.4)
11
6.3 (4.4)
28.6 %
-0.29 [ -1.15, 0.57 ]
Pulvermuller 2001
10
53 (7.24)
54 (8.16)
22.7 %
-0.12 [ -1.09, 0.84 ]
Subtotal (95% CI)
38
100.0 %
0.00 [ -0.46, 0.46 ]
36

-2
-1

135
Receptive language: auditory comprehension (treated items).
Review:

Outcome: 4 Receptive language: auditory comprehension (treated items)
Study or subgroup
Task Specific SLT
Conventional SLT
Mean Difference
Mean(SD)
Mean(SD)
10
28.1 (9.3)
11
30.1 (4.9)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Word comprehension (phonology)

Prins 1989
Subtotal (95% CI)
10
11
100.0 %
-2.00 [ -8.45, 4.45 ]
100.0 %
-2.00 [ -8.45, 4.45 ]
100.0 %
-5.00 [ -22.80, 12.80 ]

2 Word comprehension (lexicon)
Prins 1989
Subtotal (95% CI)
10
69.4 (21.8)
10
11
74.4 (19.6)
11
100.0 % -5.00 [ -22.80, 12.80 ]

3 Sentence comprehension (morphosyntax)
Prins 1989
Subtotal (95% CI)
10
78.7 (45.7)
10
11
100.0 %
92.7 (45.1)
11
-14.00 [ -52.89, 24.89 ]
100.0 % -14.00 [ -52.89, 24.89 ]

-100
-50

50
100
136
Receptive language: reading comprehension.
Review:

Study or subgroup
Task Specific SLT
Conventional SLT
Mean Difference
Mean(SD)
Mean(SD)
10
35.9 (12.9)
11
30.9 (14)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Reading comprehension
Prins 1989
Subtotal (95% CI)
10
100.0 %
5.00 [ -6.51, 16.51 ]
100.0 % 5.00 [ -6.51, 16.51 ]
11

-20
-10
10
20
Review:

Study or subgroup
Task Specific SLT
Conventional SLT
Mean Difference
Mean(SD)
Weight
IV,Fixed,95% CI
Mean Difference
Mean(SD)
IV,Fixed,95% CI
Lincoln 1982i
12.57 (0.4)
6 12.53 (1.25)
42.2 %
0.04 [ -1.01, 1.09 ]
Lincoln 1982ii
6 12.58 (1.15)
6 13.26 (0.46)
47.4 %
-0.68 [ -1.67, 0.31 ]
Lincoln 1984b
6 11.02 (2.16)
6 10.86 (1.54)
10.3 %
0.16 [ -1.96, 2.28 ]
Subtotal (95% CI)
18
18
100.0 % -0.29 [ -0.97, 0.39 ]

-4
-2

137
Expressive language: spoken naming.
Review:

Outcome: 7 Expressive language: spoken naming
Study or subgroup
Task Specific SLT
Conventional SLT
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Lincoln 1982i
10.5 (6.16)
13.5 (7.53)
16.8 %
-0.40 [ -1.55, 0.75 ]
Lincoln 1982ii
6 12.83 (7.86)
6 17.33 (5.24)
16.1 %
-0.62 [ -1.79, 0.55 ]
13.3 (14.9)
29.8 %
0.27 [ -0.59, 1.13 ]
7 54.14 (7.01)
23.3 %
0.34 [ -0.64, 1.31 ]
14.0 %
0.37 [ -0.89, 1.63 ]
100.0 %
0.04 [ -0.43, 0.51 ]
100.0 %
0.70 [ -0.60, 2.00 ]
100.0 %
0.70 [ -0.60, 2.00 ]
1 Naming
Prins 1989
10
17 (10.8)
Pulvermuller 2001
10
56.5 (6.35)
29.4 (2.3)
Subtotal (95% CI)
37
11
27 (7.97)
35

2 Naming (3-week follow up)
Subtotal (95% CI)
31.8 (3.35)
26.6 (8.88)

-2
-1

138
Expressive language: spoken sentence construction.
Review:

Outcome: 8 Expressive language: spoken sentence construction
Study or subgroup
Task Specific SLT
Conventional SLT
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
10
19 (15.2)
11
17.7 (24.8)
67.7 %
0.06 [ -0.80, 0.92 ]
3.2 (1.3)
3.4 (3.36)
32.3 %
-0.07 [ -1.31, 1.17 ]
Subtotal (95% CI)
15
100.0 %
0.02 [ -0.69, 0.72 ]
100.0 %
-0.25 [ -1.50, 1.00 ]
100.0 %
-0.25 [ -1.50, 1.00 ]
1 Sentence construction (AmAT)

Prins 1989
16

2 Sentence construction (AmAT) 3-week follow up
Subtotal (95% CI)
3 (1.58)
3.6 (2.61)

-4
-2

139
Expressive language: other spoken tasks.
Review:

Outcome: 9 Expressive language: other spoken tasks
Study or subgroup
Task Specific SLT
Conventional SLT
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Lincoln 1982i
8.83 (5.85)
16.5 (6.06)
47.8 %
-1.19 [ -2.46, 0.08 ]
Lincoln 1982ii
14.5 (12.58)
24 (4.77)
52.2 %
-0.92 [ -2.14, 0.30 ]
1 Word fluency
Subtotal (95% CI)
12
100.0 % -1.05 [ -1.93, -0.17 ]
12

Lincoln 1982i
6 38.83 (17.07)
6 30.67 (16.21)
52.8 %
0.45 [ -0.70, 1.61 ]
Lincoln 1982ii
6 36.67 (4.89)
47.2 %
-0.93 [ -2.15, 0.29 ]
100.0 %
-0.20 [ -1.04, 0.64 ]
Subtotal (95% CI)
23 (18.55)
12
12

Lincoln 1982i
11.33 (1.43)
6 10.61 (2.34)
35.4 %
0.34 [ -0.80, 1.49 ]
Lincoln 1982ii
10.39 (2)
6 12.37 (0.95)
28.9 %
-1.17 [ -2.43, 0.10 ]
Lincoln 1984b
5.09 (2.26)
35.7 %
-0.26 [ -1.39, 0.88 ]
100.0 %
-0.31 [ -0.99, 0.37 ]
Subtotal (95% CI)
18
5.61 (1.4)
18

-4
-2

140
Expressive language: spoken (treated items).
Review:

Outcome: 10 Expressive language: spoken (treated items)
Study or subgroup
Task Specific SLT
Conventional SLT
Mean Difference
Mean(SD)
Mean(SD)
35 (5.15)
27 (8.16)
Subtotal (95% CI)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Naming (treated)
100.0 %
8.00 [ -0.46, 16.46 ]
100.0 % 8.00 [ -0.46, 16.46 ]

2 Sentence construction (treated)
Subtotal (95% CI)
8 (2.74)
4.8 (4.02)
100.0 %
3.20 [ -1.06, 7.46 ]
100.0 % 3.20 [ -1.06, 7.46 ]

3 Naming (treated: 3-week follow up)
Subtotal (95% CI)
33.2 (3.96)
100.0 %
27 (6.36)
6.20 [ -0.37, 12.77 ]
100.0 % 6.20 [ -0.37, 12.77 ]

4 Sentence construction (treated: 3-week follow up)
Subtotal (95% CI)
7.6 (3.78)
3.6 (4.51)
100.0 %
4.00 [ -1.16, 9.16 ]
100.0 % 4.00 [ -1.16, 9.16 ]

-20
-10

10
20
141
Expressive language: repetition.
Review:

Study or subgroup
Task Specific SLT
Conventional SLT
Mean Difference
Mean(SD)
Mean(SD)
10
52.5 (4.22)
53.14 (8.23)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 AAT repetition subtest

Pulvermuller 2001
Total (95% CI)
10
100.0 %
-0.64 [ -7.27, 5.99 ]
100.0 % -0.64 [ -7.27, 5.99 ]

-10
-5
10
Review:

Study or subgroup
Operant Training SLT
Conventional SLT
Mean Difference
Weight
IV,Fixed,95% CI
Mean Difference
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Lincoln 1982i
7.45 (1.94)
8.21 (1.59)
17.5 %
-0.76 [ -2.77, 1.25 ]
Lincoln 1982ii
7.64 (1.82)
10.22 (1.7)
17.7 %
-2.58 [ -4.57, -0.59 ]
Lincoln 1984b
7.25 (0.55)
7.65 (1.18)
64.8 %
-0.40 [ -1.44, 0.64 ]
1 PICA graphic subtest
Subtotal (95% CI)
18
18
100.0 % -0.85 [ -1.69, -0.01 ]

-4
-2

Fav Operant Training SLT
142
Severity of impairment.
Review:

Outcome: 13 Severity of impairment
Study or subgroup
Task Specific SLT
Conventional SLT
Mean Difference
Mean(SD)
Weight
IV,Fixed,95% CI
Mean Difference
Mean(SD)
IV,Fixed,95% CI
Lincoln 1982i
10.5 (0.8)
6 10.65 (1.37)
35.1 %
-0.15 [ -1.42, 1.12 ]
Lincoln 1982ii
6 10.45 (1.21)
6 12.07 (0.86)
40.1 %
-1.62 [ -2.81, -0.43 ]
Lincoln 1984b
24.8 %
-0.17 [ -1.68, 1.34 ]
1 PICA overall
Subtotal (95% CI)
8.45 (1.45)
18
8.62 (1.21)
18
100.0 % -0.74 [ -1.50, 0.01 ]

2 AAT overall
Pulvermuller 2001
Subtotal (95% CI)
10 55.58 (5.88)
10
100.0 %
54.14 (6.3)
1.44 [ -4.48, 7.36 ]
100.0 % 1.44 [ -4.48, 7.36 ]

-10
-5

10
143
Number of drop-outs for any reason.
Review:

Study or subgroup
Task Specific SLT
Conventional SLT
n/N
n/N
Odds Ratio
Weight
Odds Ratio
Shewan 1984i
6/28
1/24
100.0 %
6.27 [ 0.70, 56.40 ]
Total (95% CI)
28
24
100.0 %
6.27 [ 0.70, 56.40 ]
M-H,Random,95% CI
M-H,Random,95% CI
Total events: 6 (Task Specific SLT), 1 (Conventional SLT)

0.001 0.01 0.1
10 100 1000
Analysis 8.1. Comparison 8 Operant training SLT (SLTA) versus conventional SLT (SLTB), Outcome 1
Receptive language: auditory comprehension.
Review:
Comparison: 8 Operant training SLT (SLTA) versus conventional SLT (SLTB)

Study or subgroup

N
Conventional SLT
Mean(SD)
Mean Difference
Mean(SD)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Word comprehension (BDAE subtest)

Lincoln 1984b
Subtotal (95% CI)
6 39.67 (10.89)
6 38.17 (10.72)
6 39.67 (10.89)
6 38.17 (10.72)
100.0 %
1.50 [ -10.73, 13.73 ]
100.0 % 1.50 [ -10.73, 13.73 ]

2 Peabody PCT
Lincoln 1984b
Subtotal (95% CI)
100.0 %
1.50 [ -10.73, 13.73 ]
100.0 % 1.50 [ -10.73, 13.73 ]

-50
-25
25
50
(Continued . . . )

144
(. . .
Study or subgroup

N
Conventional SLT
Mean(SD)
Mean Difference
Mean(SD)
Weight
IV,Fixed,95% CI
Continued)
Mean Difference
IV,Fixed,95% CI
3 Token Test
Lincoln 1982i
6 67.83 (14.82)
6 60.33 (17.24)
43.8 %
7.50 [ -10.69, 25.69 ]
Lincoln 1982ii
6 62.5 (25.36)
6 66.33 (14.47)
26.5 %
-3.83 [ -27.19, 19.53 ]
Lincoln 1984b
6 36.83 (21.24)
6 27.67 (17.61)
29.7 %
9.16 [ -12.92, 31.24 ]
Subtotal (95% CI)
18
18
100.0 % 4.99 [ -7.05, 17.02 ]

-50
-25
25
50
Review:

Study or subgroup
Conventional SLT
Mean Difference
Mean(SD)
Weight
IV,Fixed,95% CI
Mean Difference
Mean(SD)
IV,Fixed,95% CI
Lincoln 1982i
12.57 (0.4)
6 12.53 (1.25)
42.2 %
0.04 [ -1.01, 1.09 ]
Lincoln 1982ii
6 12.58 (1.15)
6 13.26 (0.46)
47.4 %
-0.68 [ -1.67, 0.31 ]
Lincoln 1984b
6 11.02 (2.16)
6 10.86 (1.54)
10.3 %
0.16 [ -1.96, 2.28 ]
Subtotal (95% CI)
18
18
100.0 % -0.29 [ -0.97, 0.39 ]

-4
-2

145
Expressive language: spoken.
Review:

Study or subgroup
Conventional SLT
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Lincoln 1982i
10.5 (6.16)
13.5 (7.53)
33.6 %
-0.40 [ -1.55, 0.75 ]
Lincoln 1982ii
6 12.83 (7.86)
6 17.33 (5.24)
32.2 %
-0.62 [ -1.79, 0.55 ]
Lincoln 1984b
34.2 %
0.24 [ -0.90, 1.38 ]
100.0 %
-0.25 [ -0.92, 0.41 ]
1 Naming
Subtotal (95% CI)
0.83 (1.6)
18
0.5 (0.84)
18

2 Word fluency
Lincoln 1982i
8.83 (5.85)
16.5 (6.06)
47.8 %
-1.19 [ -2.46, 0.08 ]
Lincoln 1982ii
6 14.5 (12.58)
24 (4.77)
52.2 %
-0.92 [ -2.14, 0.30 ]
Subtotal (95% CI)
12
100.0 % -1.05 [ -1.93, -0.17 ]
12

Lincoln 1982i
6 38.83 (17.07)
6 30.67 (16.21)
52.8 %
0.45 [ -0.70, 1.61 ]
Lincoln 1982ii
6 36.67 (4.89)
47.2 %
-0.93 [ -2.15, 0.29 ]
100.0 %
-0.20 [ -1.04, 0.64 ]
Subtotal (95% CI)
23 (18.55)
12
12

Lincoln 1982i
6 11.33 (1.43)
6 10.61 (2.34)
35.4 %
0.34 [ -0.80, 1.49 ]
Lincoln 1982ii
10.39 (2)
6 12.37 (0.95)
28.9 %
-1.17 [ -2.43, 0.10 ]
Lincoln 1984b
5.09 (2.26)
35.7 %
-0.26 [ -1.39, 0.88 ]
100.0 %
-0.31 [ -0.99, 0.37 ]
Subtotal (95% CI)
18
5.61 (1.4)
18

-4
-2

146
Review:

Study or subgroup
Conventional SLT
Mean Difference
Weight
IV,Fixed,95% CI
Mean Difference
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Lincoln 1982i
7.45 (1.94)
8.21 (1.59)
17.5 %
-0.76 [ -2.77, 1.25 ]
Lincoln 1982ii
7.64 (1.82)
10.22 (1.7)
17.7 %
-2.58 [ -4.57, -0.59 ]
Lincoln 1984b
7.25 (0.55)
7.65 (1.18)
64.8 %
-0.40 [ -1.44, 0.64 ]
1 PICA graphic subtest
Subtotal (95% CI)
18
100.0 % -0.85 [ -1.69, -0.01 ]
18

-4
-2
Severity of impairment.
Review:

Outcome: 5 Severity of impairment
Study or subgroup
Conventional SLT
Mean Difference
Mean(SD)
Weight
IV,Fixed,95% CI
Mean Difference
Mean(SD)
IV,Fixed,95% CI
Lincoln 1982i
10.5 (0.8)
6 10.65 (1.37)
35.1 %
-0.15 [ -1.42, 1.12 ]
Lincoln 1982ii
6 10.45 (1.21)
6 12.07 (0.86)
40.1 %
-1.62 [ -2.81, -0.43 ]
Lincoln 1984b
24.8 %
-0.17 [ -1.68, 1.34 ]
1 PICA overall
Subtotal (95% CI)
8.45 (1.45)
18
8.62 (1.21)
100.0 % -0.74 [ -1.50, 0.01 ]
18

-4
-2

147
Analysis 9.1. Comparison 9 Semantic SLT (SLTA) versus phonological SLT (SLT B), Outcome 1 Functional
communication.
Review:
Comparison: 9 Semantic SLT (SLTA) versus phonological SLT (SLT B)

Study or subgroup
Semantic SLT
Phonological SLT
Mean Difference
Mean(SD)
Mean(SD)
Doesborgh 2004a
29
29.9 (12)
26
29.5 (11)
Subtotal (95% CI)
29
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 ANELT-A
100.0 %
0.40 [ -5.68, 6.48 ]
100.0 % 0.40 [ -5.68, 6.48 ]
26

-20
-10
Favours Phonological SLT

10
20
Favours Semantic SLT
148
Analysis 9.2. Comparison 9 Semantic SLT (SLTA) versus phonological SLT (SLT B), Outcome 2 Receptive
language: auditory.
Review:

Outcome: 2 Receptive language: auditory
Study or subgroup
Semantic SLT
Phonological SLT
Mean(SD)
Mean Difference
Mean(SD)
23
1.6 (4.04)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Semantic Association Test: PALPA (change from baseline)

Doesborgh 2004a
23
Subtotal (95% CI)
23
2.9 (3.93)
23
100.0 %
1.30 [ -1.00, 3.60 ]
100.0 %
1.30 [ -1.00, 3.60 ]
100.0 %
-3.50 [ -6.23, -0.77 ]

2 Auditory lexical decision: PALPA (change from baseline)
Doesborgh 2004a
23
Subtotal (95% CI)
23
-0.5 (5.32)
23
3 (4.04)
23
100.0 % -3.50 [ -6.23, -0.77 ]

-10
-5
10
Analysis 9.3. Comparison 9 Semantic SLT (SLTA) versus phonological SLT (SLT B), Outcome 3 Receptive
language: reading.
Review:

Outcome: 3 Receptive language: reading
Study or subgroup
Semantic SLT
N
Phonological SLT
Mean(SD)
Mean Difference
Mean(SD)
23
0.1 (5.43)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Synonym judgement: PALPA (change from baseline)

Doesborgh 2004a
Total (95% CI)
23
1.7 (6.47)
23
100.0 %
1.60 [ -1.85, 5.05 ]
100.0 % 1.60 [ -1.85, 5.05 ]
23

-10
-5

10
149
Analysis 9.4. Comparison 9 Semantic SLT (SLTA) versus phonological SLT (SLT B), Outcome 4 Expressive
language: repetition.
Review:

Study or subgroup
Semantic SLT
Phonological SLT
Mean Difference
Mean(SD)
Mean(SD)
1.3 (5.66)
23
3 (3.81)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Non-words: PALPA (change from baseline)

Doesborgh 2004a
23
Subtotal (95% CI)
23
100.0 %
23
-1.70 [ -4.49, 1.09 ]
100.0 % -1.70 [ -4.49, 1.09 ]

-10
-5
Favours Phonology
10
Favours Semantic
Analysis 9.5. Comparison 9 Semantic SLT (SLTA) versus phonological SLT (SLT B), Outcome 5 Number of
drop-outs for any reason.
Review:

Study or subgroup
Semantic SLT
Phonological SLT
n/N
n/N
6/29
6/29
100.0 %
1.00 [ 0.28, 3.56 ]
29
29
100.0 %
1.00 [ 0.28, 3.56 ]
Doesborgh 2004a
Total (95% CI)
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
Total events: 6 (Semantic SLT), 6 (Phonological SLT)

0.01
0.1
Favours Semantic
10
100
Favours Phonology

150
Analysis 10.1. Comparison 10 Filmed programmed instruction SLT (SLT A) versus non-programmed
activity SLT (SLTB), Outcome 1 Receptive language: auditory.
Review:
Comparison: 10 Filmed programmed instruction SLT (SLT A) versus non-programmed activity SLT (SLTB)
Outcome: 1 Receptive language: auditory
Study or subgroup Programme Instruction SLT

N
Non-Prog Instruction SLT
Mean Difference
Mean(SD)
Mean(SD)
7 22.43 (2.76)
21.71 (3.2)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Word comprehension
Di Carlo 1980
Total (95% CI)
100.0 %
0.72 [ -2.41, 3.85 ]
100.0 % 0.72 [ -2.41, 3.85 ]

-10
-5
Fav Non-Prog Inst SLT
10
Fav Prog Inst SLT
Analysis 10.2. Comparison 10 Filmed programmed instruction SLT (SLT A) versus non-programmed
activity SLT (SLTB), Outcome 2 Receptive language: reading.
Review:
Comparison: 10 Filmed programmed instruction SLT (SLT A) versus non-programmed activity SLT (SLTB)
Outcome: 2 Receptive language: reading
Study or subgroup
Programme Instruction SLT
Non-Prog Instruction SLT
Mean Difference
Mean(SD)
Mean(SD)
4.56 (1.31)
4.64 (1.4)
Weight
IV,Fixed,95% CI
Mean Difference
IV,Fixed,95% CI
1 Reading comprehension
Di Carlo 1980
Subtotal (95% CI)
100.0 %
-0.08 [ -1.50, 1.34 ]
100.0 % -0.08 [ -1.50, 1.34 ]

2 Reading recognition
Di Carlo 1980
Subtotal (95% CI)
4.27 (1.28)
100.0 %
4.37 (1.3)
-0.10 [ -1.45, 1.25 ]
100.0 % -0.10 [ -1.45, 1.25 ]

-4
-2
Fav Non-Prog Instruction

Fav Prog Instruction SLT
151
ADDITIONAL TABLES
Table 1. Characteristics of participants in included studies
Study ID
Number
Male/female
Bakheit 2007
97
Intensive: 26/25
Intensive:
71.2
Conventional: 21/ (14.9) (range 26 to
25
92)
Conventional: 69.7
(15) (range 17 to
91)
David 1982
133 (of 155 ran- Conventional: 35/ Conventional: 70 Conventional: me- Not reported
domised)
30
(8.7)
dian 4 (range 4 to
Social support: 42/ Social support: 65 266) weeks
26
(10.6)
Social support: median 5 (range 4 to
432) weeks
Denes 1996
17
Intensive: 5/3
Conventional: 3/6
Intensive:
58.1 Intensive: 3.2 (1.8)
(11.8)
months
Conventional: 62.1 Conventional:
3
(8.7)
(1.6) months
AAT
Intensive: severe
Conventional:
severe
Di Carlo 1980
14
Programmed
instruction: 7/0
Non-programmed
instruction: 7/0
Programmed
instruction: 57.6 (9.2)
(range 44 to 69)
Non-programmed
instruction:
55.3 (13) (range 32
to 70)
Programmed
instruction: severe
Non-programmed
instruction: severe
Doesborgh 2004a
58
Semantic: 18/11
Phonologic: 15/14
Semantic: 66 (10)
Semantic:
Phonologic: 58 (14) mean 4 (range 3 to
5) months
Phonologic: mean
4 (range 3 to 5)
months
ANELT-A score
Semantic: 24.8 (11)
Phonologic: 23.3
(8)
Doesborgh 2004b
18
(of
randomised)
Computermediated: 62 (9.0)
No SLT: 65 (12.0)
Computer-mediated: ANELT- A 34
(9); BNT 63 (37)
No SLT: ANELT-A
29 (12); BNT 74
19 Computermediated: 4/4
No SLT: 5/5
Age in years mean Post-onAphasia

sever(standard
set mean (standard ity mean (standard
deviation)
deviation) (range) deviation)

Intensive:
34.2 WAB scores
(19.1) days
Intensive:
44.2
Conventional: 28.1 (30.2)
(14.9) days
Conventional: 37.9
(27.2)
Programmed
instruction:
24.7 (23.6) (range 0
to 66) months
Non-programmed
instruction:
16.3 (16.9) (range 1
to 38) months
Computermediated: 13 (range
11 to 16) months
No SLT: 13 (range
11 to 17) months
152
(Continued)
(35)
Drummond 1981
Not reported
Gesture cue: 52.9 Gesture cue: 15.3 Not reported

(6.0)
(4.1) (range 10 to
Conventional:
20) months
50.04 (4.5)
Conventional: 17.8
(7.1) (range 9 to 24)
months
Elman 1999
24
Conventional: 7/5
Social support: 6/6
Conventional: 58.3
(11.4) (range 38 to
79)
Social support: 60.7
(10.6) (range 47 to
80)
Conventional: 32.5
(28.7) (range 7 to
103) months
Social support: 71.7
(94.2) (range 7 to
336) months
Conventional:
SPICA 7 mild-moderate, 7 moderate to
severe
Social support: SPICA
7 mild-moderate, 7
moderate to severe
Hinckley 2001
12
Functional SLT: 5/1 Functional:

51.6 Functional:
Conventional SLT: (15)
26.8 (20.1) (range 6
6/0
Conventional: 50.3 to 58) months
(13.6)
Conventional: 26.8
(37.6) (range 4 to
102) months
BDAE Severity Rating

Functional:
2.5
(0.8)
Conventional: 1.83
(0.9)
Jufeng 2005i
60
Group SLT: unclear

No SLT: unclear
(Jufeng 2005: 50/
34)
Group SLT: unclear Unclear

No SLT: unclear
(Jufeng 2005: < 40
years = 3; 40s = 23;
50s = 23; 60s = 25;
70s = 8; > 80 years =
2)
Unclear
Jufeng 2005ii
54
Group SLT: unclear

No SLT: unclear
(Jufeng 2005: 50/
34)

No SLT: unclear
(Jufeng 2005: < 40
years = 3; 40s = 23;
50s = 23; 60s = 25;
70s = 8; > 80 years =
2)
Unclear
Jufeng 2005iii
54
Group SLT: unclear

No SLT: unclear
(Jufeng 2005: 50/
34)

No SLT: unclear
(Jufeng 2005: < 40
years = 3; 40s = 23;
50s = 23; 60s = 25;
70s = 8; > 80 years =
2)
Unclear

153
(Continued)
Katz 1997i
42 (reported data on Computer36)

mediated: unclear
No SLT: unclear
(Katz 1997: 44/11)
Computer-mediated: 61.6 (10)

No SLT: 62.8 (5.1)
ComNot reported
puter-mediated: 6.2
(5.2) years
No SLT: 8.5 (5.4)
years
Katz 1997ii
40
(of
randomised)
Computer-mediated: 61.6 (10)

Computer placebo:
66.4 (6)
Compute-mediNot reported
ated: 6.2 (5.2) years
Computer placebo:
5.4 (4.6) years
Leal 1993
94
Conventional: 38/
21
Volunteerfacilitated: 22/13
Conventional: 56 Within first month Conventional:

(17)
after stroke
moderate-severe
VolunteerVolunteer-facilfacilitated: 59 (13)
itated: moderate-severe
Lincoln 1982i
12
SLT/operant train:
3/3
SLT/Social support:
4/2
SLT/Operant train:
54.33 (6.68) (range
45 to 63)
SLT/Social support:
51.33 (7.97) (range
39 to 63)
SLT/Operant train:
3.17 (1.60) (range 1
to 5) months
SLT/Social support:
5.17 (3.43) (range 1
to 10) months
SLT/Operant train:
moderate
SLT/Social support:
moderate
Lincoln 1982ii
12
Operant train/SLT:
5/1
Social support/SLT:
5/1
Operant train/SLT:
57.67 (5.72) (range
51 to 64)
Social support/SLT:
42.33
(16.91)
(range 28 to 60)
Operant train/SLT:
2.33 (1.55) (range 1
to 5) months
Social support/SLT:
8.83 (13.59) (range
1 to 36) months
Operant train/SLT:
moderate
Social support/SLT:
moderate
Lincoln 1982iii
18
Conventional SLT: Conventional SLT: Conventional SLT:

7/5
52.83 (7.18) (range 4.17 (2.76) (range 1
Social support: 5/1 39 to 63)
to 10)
Social
sup- Social support: 8.83
port: 42.33 (16.91) (13.59) (range 1 to
(range 28 to 60)
36) months
Conventional SLT:
moderate
Social
support:
moderate
Lincoln 1984a
191
(Data for 58% of (of
randomised partici- randomised)
pants)
Lincoln 1984b
12
42 Computermediated: unclear
Computer placebo:
unclear
(Katz 1997: 44/11)
Conventional: un327 clear

No SLT: unclear
(Lincoln
1984a:
109/ 82)
Operant train: 4/2

Placebo: 5/1
Conventional: un- Conventional: 10 Not reported

clear
weeks
No SLT: unclear
No SLT: 10 weeks
Lincoln 1984a: 68.2
(10.2) (range 38 to
92)
Operant
Operant train: 5.5 Operant train: setrain: 52.33 (11.50) (4.89) (range 1 to vere

154
(Continued)
(range 32 to 64)
12) months
Placebo: severe
Placebo: 52.5 (14.9) Placebo:
(range 26 to 66)
2.83 (2.32) (range 1
to 7) months
Lyon 1997
30
Functional: unclear
No SLT: unclear
(Lyon 1997: person
with aphasia: 8/2;
caregiver: 4/6; communication partner:
1/9)
Functional: unclear
No SLT: unclear
(Lyon 1997: person with aphasia:
68.6 (12.1) (range
54 to 86); caregiver
60.2 (14.9) (range
28 to 84); communication partner:
44.9 (17.5) (range
25 to 74))
MacKay 1988
95
(of 96 randomised)
MacKay 1988: 46/ MacKay 1988: me- MacKay

1988: Not reported
49
dian 75
mean 30 months
Meikle 1979
31
VolunteerVolunteer-facilifacilitated: 12/3
tated: 67.2 (8.6)
Conventional: 10/6 Conventional: 64.8
(7.9)
Volunteer-facilitated: 30.9
(29.5) (range 4 to
115) weeks
Conventional: 39.8
(69.4) (range 4 to
268) weeks
PICA
percentile
Volunteer-facilitated: 53.9 (23.5)
Conventional: 55.8
(19.78)
Meinzer 2007
20
ConstraintConstraint-ininduced: 7/3 Volun- duced: 50.2 (10.13)

teer-facilitated: 9/1 Volunteerfacilitated: 62 (8.9)
Constrain-induced:
30.7 (18.9) (range 6
to 72) months
Volunteer-facilitated: 46.5
(17.2) (range 24 to
79) months
AAT profile score

Constraintinduced: 5 mild, 3
moderate, 2 severe
Volunteerfacilitated: 3 mild, 6
moderate, 1 severe
ORLA 2006
13
Intensive SLT: 6
Intensive SLT: 61.4
Conventional SLT: (9.72) (range 48.44
7
to 74.5)
Conventional SLT:
53.1 (18.1) (range
31.34 to 77.98).
Intensive SLT: 36.2

(28.2) (range 8.6 to
69.8) months
Conventional SLT:
43.6 (51.1) (range
7.3 to 154) months
WAB Aphasia Quotient Intensive SLT:

51.1 (17.8) (range
28.0 to 69.4)
Conventional SLT: 55.1
(18) (range 34.1 to
77.1)
Prins 1989
21
STADCAP: 5/5
Conventional: 5/6
STADCAP:
15.2 (range 3 to 35)
months
Conventional: 15.2
STADCAP: FE-scale 2.6

(0 to 6), Oral comp
(BDAE and Token
STADCAP: 70.3
(range 58 to 83)
Conventional: 66
(range 45 to 78)

Functional: unclear
No SLT: unclear
(Lyon 1997: 43.5
(32.2) months)
Functional: unclear
No SLT: unclear
(Lyon 1997: receptive = mild; expressive = moderate)
155
(Continued)
(range 3 to 36) Test) 26.4 (0 to 46)

months
Conventional: FE-scale 2.7
(0 to 9), Oral comp
(BDAE and Token
Test) 29.6 (2 to 48)
Pulvermuller 2001
17
Constraintinduced: 6/4
Conventional: 6/1
Constraint-induced: 55.4 (10.9)

Conventional: 53.9
(7.4)
Constraint-induced: 98.2 (74.2)

months
Conventional: 24
(20.6) months
Constraintinduced: 2 mild, 5
moderate, 3 severe
Conventional:
2
mild, 4 moderate, 1
severe
Rochon 2005
Sentence mapping: Sentence mapping:

0/3
31 to 74
Social support: 0/2 Social support: 32
to 82
Sentence mapping:
(range 2 to 9) years
Social
support:
(range 2 to 4) years
Sentence mapping:
BDAE 1 to 2, phrase
length 2.5 to 4
Social
support: BDAE 1 to
2, phrase length 4
Shewan 1984i
52
Languageorientated: 18/10
Conventional: 14/
10
Language-orientated: 62.18 (range

29 to 82)
Conventional: 65.63 (range
48 to 85)
Languageorientated: (range 2
to 4) weeks
Conventional:
(range 2 to 4 weeks)
Languageorientated: 9 mild, 6
moderate, 13 severe
Conventional:
8 mild, 3 moderate,
13 severe
Shewan 1984ii
53
Languageorientated: 18/10
Social support: 14/
11
Language-orientated: 62.18 (range

29 to 82)
Social
support:
66.12 (range 39 to
82)
Languageorientated: (range 2
to 4) weeks
Social
support:
(range 2 to 4) weeks
Languageorientated: 9 mild, 6
moderate, 13 severe
Social support: 7
mild, 5 moderate,
13 severe
Shewan 1984iii
49
Conventional: 14/ Conven10

tional: 65.63 (range
Social support: 14/ 48 to 85)
11
Social
support:
66.12 (range 39 to
82)
Conventional:
Social
support:
Conventional:
8 mild, 3 moderate,
13 severe
Social support: 7
mild, 5 moderate,
13 severe
Smania 2006
33
(of
randomised)
Conventional: 17.4
(24.07) (range 2 to
36) months
No
SLT:
10.39 (7.96) (range
3 to 32) months
Aphasia
severity:
unclear
Neurological severity:
Conventional: 6.07
(4.3) (range 0 to16)
No SLT: 6.94 (5.83)
41 Conventional: 11/4
No SLT: 12/6
Conventional:
65.73 (8.78) (range
48 to 77)
No
SLT:
65.67 (9.83) (range
41 to 77)

156
(Continued)
(range 0 to 15)
Smith 1981i
33
Intensive: 12/4
No SLT: 10/7
Intensive: 62
No SLT: 65
Not reported
MTDDA (mean error score percentage)

Intensive: 39
No SLT: 26
Smith 1981ii
31
Conventional: 10/4
No SLT : 10/7
Conventional: 63
No SLT: 65
Not reported

Conventional: 44
No SLT: 26
Smith 1981iii
30
Intensive: 12/4
Intensive: 62
Conventional: 10/4 Conventional: 63
Not reported

Intensive: 39
Conventional: 44
van Steenbrugge
1981
10
Task-specific: 0/5
Conventional: 2/3
Task-specific: 61.8
(17.05) (range 40 to
77)
Conventional: 63.6
(10.9) (range 48 to
77)
Task-specific:
21 (22.4) (range 5 to
60) months
Conventional: 20.6
(23.7) (range 5 to
60) months
FEscale and M-S Comprehension Test

Task-specific:
4
(1.9)
Conventional:
6
(2.9)
Wertz 1981
67
Not reported
(15 weeks after Group SLT: 4 weeks

stroke)
Conventional:
4
Group SLT: 60.24 weeks
(range 40 to 79)
41 to 79)
(15 weeks after

stroke)
PICA overall percentile
Group SLT: 45.21
(range 15 to 74)
16 to 74)
Wertz 1986i
78
Conventional: un- Conventional: 59.2 Conventional: 6.6

clear
(6.7)
(4.8) weeks
No SLT: unclear
No SLT: 57.2 (6.8) No SLT: 7.8 (6.6)
weeks
PICA
overall percentile Conventional:
46.59
(16.05)
No SLT: 49.18
(19.46)
Wertz 1986ii
83
No SLT: unclear

Volunteerfacilitated: 49.97
Volunteer-facilitated: 60.2 (6.7)

No SLT: 57.2 (6.8)

Volunteerfacilitated: 7.1 (5.8)

weeks
No SLT: 7.8 (6.6)
157
(Continued)
weeks
Wertz 1986iii
81
Conventional: unclear
Volunteer-facilitated:60.2 (6.7)
Conventional: 59.2
(6.7)
Wu 2004
236
Conventional: unclear
No SLT: unclear
(Wu 2004: 159/ 77)
Conventional:
Not reported
(range 39 to 81)
No SLT: (range 40
to 78)
(22.77)
No SLT:
(19.46)
Volunteerfacilitated: 7.1 (5.8)

weeks
Conventional: 6.6
(4.8) weeks
49.18

Volunteerfacilitated: 49.97
(22.77)
Conventional:
46.59 (16.05)
Not reported
AAT: Aachen Aphasia Test

BNT: Boston Naming Test
FE-scale: Functional-Expression scale
MTDDA: Minnesota Test for the Differential Diagnosis of Aphasia
PICA: Porch Index of Communicative Abilities
SLT: speech and language therapy/therapist
SPICA: Shortened Porch Index of Communicative Abilities
STACDAP: systematic therapy for auditory comprehension disorders in aphasic patients
WAB: Western Aphasia Battery
Table 2. Details of drop-outs
Study ID
Intervention
Reasons
Follow up
Bakheit 2007
Intensive: 16
Conventional: 8
Intensive: 2 died, 14 with- Intensive: 4

drew
Conventional: 3
Conventional: 8 withdrew
(Across trial: withdrew 13,
died 4, illness 4, not tolerating therapy 3, relocation
2, further stroke 1, diagnosis revised 1)
Not reported
David 1982
Conventional: 23
Social support: 36
Conventional: 4 died; 5 Conventional: 11

new stroke; 2 self dis- Social support: 12
charge; 5 illness , 3 moved,
4 other
Social support: 6 died, 5
Not reported

Reasons
158
(Continued)
new stroke, 5 transport,

6 self-discharge, 3 illness,
4 volunteer issues, 2 relocated, 5 other undescribed
Doesborgh 2004a
Semantic: 6
Phonological: 6
Semantic: 4 received less No follow up

than 40 hours treatment,
2 severe neurological illness
Phonological: 2 received
less than 40 hours treatment, 1 severe neurological illness, 3 ANELT score
missing (2 refused, 1 missing)
Doesborgh 2004b
Computer-mediated: 1
No SLT: 0
Computer-mediated:
illness
No SLT: 0
Elman 1999
Conventional: 2
Social support: 3
Conventional: 1 trans- Conventional: 0

port, 1 time constraints, 1 Social support: 0
medical complications
Social support: 2 time
constraints
Katz 1997i
No SLT: 6
Prolonged illness, new Computer-mediated: 0

stroke, death
No SLT: 0
Katz 1997ii
Prolonged illness, new Computer-mediated: 0
No
SLT
(computer stroke, death
No
SLT
(computer
placebo): 2
placebo): 0
Leal 1993
Conventional: 21
Volunteer-facilitated: 13
Lincoln 1982i
Social support: ? Operant Homesickness, illness

training: ?
(13: groups unclear)
No follow up
Lincoln 1982ii

training: ?
No follow up
1 No follow up
Conventional: 2 death, 3 Conventional: 0

new stroke, 3 transport; 4 Volunteer-facilitated: 0
refused, 2 moved, 5 illness,
2 transfer
Volunteerfacilitated: 1 death, 1 new
stroke, 3 transport, 4 refused, 2 moved, 0 illness,
2 transfer

159
(Continued)

Lincoln 1982iii

training: ?
No follow up
Lincoln 1984a
Conventional: 78
No SLT: 79
Death, refused, illness, re- No follow up

covered, unsuitable, relocated
MacKay 1988
No SLT: 1
Reason not reported
Meikle 1979
Conventional: 0
Conventional: 0
No follow up
Volunteer-facilitated: 1 refused, 1 moved
Shewan 1984i
Language orientated: 6
Conventional: 1
Language orientated: 1 No follow up

death, 2 relocation, 3
withdrew
Conventional: 1 death
Shewan 1984ii
Language orientated: 6
Social support: 6
Language orientated: 1 No follow up

death, 2 relocation, 3
withdrew
Social support: 1 death,
2 illness, 1 relocation, 2
withdrew
Shewan 1984iii
Conventional: 1
Social support: 6
Conventional: 1 death
No follow up
Social support: 1 death,
2 illness, 1 relocation, 2
withdrew
Smania 2006
Conventional: 5
No SLT: 3
Conventional: 3 unco-op- Conventional: 7

erative, 2 illness
No SLT: 9
No SLT: 1 unco-operative,
2 illness
Conventional: 3 illness, 4
refused
No SLT: 1 death, 2 illness,
4 refused, 2 relocated
Smith 1981i
Intensive: 6
No SLT: not reported
Reasons not detailed

Intensive: 4
Additional 5 withdrawn No SLT: not reported
but not advised of groupings
Not reported
Smith 1981ii
Conventional: 2
No SLT: not reported

Conventional: 4
Additional 5 withdrawn No SLT: not reported
Not reported
No follow up

160
(Continued)
Smith 1981iii
Intensive: 6
Conventional: 2

Intensive: 4
Additional 5 withdrawn Conventional: 4
Not reported
Wertz 1981
Group: 17
Conventional: 16
22 self-discharged (return No follow up

home or declined to
travel), 4 illness, 2 stroke,
3 died, 2 returned to work
Wertz 1986i
Conventional: 7
No SLT: 5
Illness, new stroke
Conventional: 2
No SLT: 6
Illness, new stroke
Wertz 1986ii
No SLT: 5
Illness, new stroke
No SLT: 6
Illness, new stroke
Wertz 1986iii
Conventional: 7
Illness, new stroke
Conventional: 2
Illness, new stroke

APPENDICES
Appendix 1. MEDLINE search strategy
1. exp aphasia/
2. language disorders/ or anomia/
3. (aphasi$ or dysphasi$ or anomia or anomic).tw.
4. ((language or linguistic) adj5 (disorder$ or impair$ or problem$ or dysfunction)).tw.
5. 1 or 2 or 3 or 4
6. language therapy/ or speech therapy/
7. Speech-Language Pathology/
8. ((speech or language or aphasia or dysphasia) adj5 (therap$ or train$ or rehabilitat$ or treat$ or remediat$ or pathol$)).tw.
9. remedial therap$.tw.
10. 6 or 7 or 8 or 9
11. 5 and 10
12. exp aphasia/rh, th or language disorders/rh, th or anomia/rh, th
13. 11 or 12
14. Randomized Controlled Trials/
15. random allocation/
16. Controlled Clinical Trials/
17. control groups/
18. clinical trials/
19. double-blind method/
161
20. single-blind method/

21. Multicenter Studies/
22. Therapies, Investigational/
23. Research Design/
24. Program Evaluation/
25. evaluation studies/
26. randomized controlled trial.pt.
27. controlled clinical trial.pt.
28. clinical trial.pt.
29. multicenter study.pt.
30. evaluation studies.pt.
31. random$.tw.
32. (controlled adj5 (trial$ or stud$)).tw.
33. (clinical$ adj5 trial$).tw.
34. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
35. (quasi-random$ or quasi random$ or pseudo-random$ or pseudo random$).tw.
36. ((multicenter or multicentre or therapeutic) adj5 (trial$ or stud$)).tw.
37. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
38. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
39. (coin adj5 (flip or flipped or toss$)).tw.
40. latin square.tw.
41. versus.tw.
42. (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
43. controls.tw.
44. or/14-43
45. 13 and 44
46. child$.ti.
47. 45 not 46
Appendix 2. CINAHL search strategy

1. aphasia/ or aphasia, broca/ or aphasia, wernicke/
2. Language Disorders/
3. (aphasi$ or dysphasi$ or anomia or anomic).tw.
4. ((language or linguistic) adj5 (disorder$ or impair$ or problem$ or dysfunction)).tw.
5. 1 or 2 or 3 or 4
6. rehabilitation, speech and language/ or alternative and augmentative communication/ or language therapy/ or exp speech,
alaryngeal/ or speech therapy/
7. Speech-Language Pathology/ or communication skills training/
8. Speech-Language Pathologists/
9. ((speech or language or aphasia or dysphasia) adj5 (therap$ or train$ or rehabilitat$ or treat$ or pathol$)).tw.
10. 6 or 7 or 8 or 9
11. 5 and 10
12. language disorders/rh, th or aphasia/rh, th or aphasia, broca/rh, th or aphasia, wernicke/rh, th
13. 11 or 12
14. random assignment/
15. random sample/
16. Crossover design/
17. exp Clinical trials/
18. Comparative studies/
19. control (research)/
20. Control group/
162
21. Factorial design/

22. quasi-experimental studies/
23. Nonrandomized trials/
24. Clinical nursing research/ or Clinical research/
25. Community trials/ or Experimental studies/ or One-shot case study/ or Pretest-posttest design/ or Solomon four-group design/ or
Static group comparison/ or Study design/
26. clinical trial.pt.
27. random$.tw.
28. ((singl$ or doubl$ or tripl$ or trebl$) adj25 (blind$ or mask$)).tw.
29. (cross?over or control$ or factorial or sham?).tw.
30. ((clin$ or intervention$ or compar$ or experiment$ or therapeutic) adj10 trial$).tw.
31. (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline$ or ABAB design$).tw.
32. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
33. or/14-32
34. 13 and 33
35. 34 not child$.ti.
Appendix 3. Speech and Language Therapy approaches
Type of SLT
Speech and Language Therapy
Study ID
Conventional
Any form of targeted practice tasks or methodologies that aim to maximise the understanding
and production of language and communication
abilities across spoken and written modalities.
Generally conducted on a patient-therapist (1to-1) basis and using stimulation-facilitation approaches
Bakheit 2007; David 1982; Denes 1996; Di

Carlo 1980; Elman 1999; Drummond 1981;
Hinckley 2001; (Jufeng 2005ii; Jufeng 2005iii)
; Leal 1993; Lincoln 1982i; Lincoln 1984a;
Lincoln 1984b; Meikle 1979; Prins 1989;
Pulvermuller 2001; Shewan 1984i; Shewan
1984iii; Smania 2006; Smith 1981i; Smith
1981ii; Smith 1981iii; van Steenbrugge 1981;
Wertz 1981; Wertz 1986i; Wertz 1986iii; (Wu
2004)
Computer-mediated
Targeted practice tasks or methodologies that Doesborgh 2004b; Katz 1997i; Katz 1997ii;
aim to improve a patients language or commu- ORLA 2006
nication abilities but that are accessed via a computer program
Constraint-induced
Participants required to use spoken communica- Meinzer 2007; Pulvermuller 2001

tion alone
Other communicative methods such as gesture
are not encouraged or permitted
Functional
Targets improvement in communication tasks Denes 1996; Elman 1999; Hinckley 2001; Lyon
considered to be useful in day-to-day function- 1997
ing
Gestural cueing
Use of gesture as a cue to facilitate word-finding Drummond 1981 (AMERIND)

163
(Continued)
Group
A SLT intervention involving 2 or more partici- Elman 1999; Jufeng 2005i; Jufeng 2005iii;
pants with aphasia
Wertz 1981
Intensive
At least 4 or more hours of therapeutic interven- Bakheit 2007; Denes 1996; ORLA 2006; Smith
tion each week
1981i; Smith 1981iii
Language-orientated
Follows psycholinguistic principles
Operant training
Not a widely practiced approach to SLT but it Lincoln 1984a; Lincoln 1982i
is a verbal conditioning procedure with the purpose (in the examples included in this review) of
improving communication skills
Phonological treatment
Focuses on improving the sound structure of lan- Doesborgh 2004a

guage
Therapy is directed at the phonological input
and output routes
Semantic treatment
Focuses on interpretation of language with the Doesborgh 2004a

aim of improving semantic processing
Sentence mapping
Targets the mapping between the meaning and Rochon 2005

syntactic structure of sentences
Task-specific
Therapy focused on specific areas of communi- Prins 1989 (STACDAP); Rochon 2005 (Sencation impairment
tence Mapping Therapy); van Steenbrugge
1981 (naming and sentence construction);
Drummond 1981 (word finding); constraintinduced therapy (Meinzer 2007; Pulvermuller
2001)
Volunteer-facilitated (trained)
Targeted practice tasks or methodologies that Leal 1993; MacKay 1988; Meikle 1979; Meinzer
aim to improve a patients language or commu- 2007; Wertz 1986ii; Wertz 1986iii
nication abilities but delivered by a volunteer
Training, material and intervention plans are
usually provided to support the volunteer
Social support and stimulation
An intervention which provides social support or Elman 1999; David 1982; Rochon 2005;
stimulation but does not include targeted inter- Shewan 1984ii; Shewan 1984iii
ventions that aim to resolve participants expressive/receptive speech and language impairments
Programmed instruction
Behavioural intervention that employs a book or Di Carlo 1980

film to present materials for learning
Participants can progress through the tasks at
their own pace, using queries to test their new
learning
Progression to the next stage only occurs once

Shewan 1984i; Shewan 1984ii
164
(Continued)
they have been successful at an earlier stage

Placebo
An intervention that mimics the experimental

intervention in nature but does not have components that aim to resolve or improve participants
expressive/receptive speech and language skills
Di Carlo 1980 (non-programmed activity); Katz

1997ii (arcade-style games: non-language computer based); Lincoln 1982i (attention non-specific); Lincoln 1984b (non-specific placebo)
Appendix 4. Assessments
Name of assessment
Abbreviation
Reference
Aachen Aphasia Test
AAT
Huber 1984
Affect Balance Scale
ABS
Bradburn 1969
Amsterdam Aphasia Test
AmAT
Prins 1980; Vermeulen 1979
Amsterdam-Nijmegen Everyday Language ANELT-A

Test-A
Blomert 1994
Auditory Comprehension Test for Sen- ACTS

tences
Shewan 1979
Boston Diagnostic Aphasia Examination
BDAE
Goodglass 1972 and Goodglass 1983
Boston Naming Test
BNT
Kaplan 1983
Caplan and Hanna Sentence Production CHSPT

Test
Caplan 1998
Chinese Rehabilitation Research Centre CRRCAE

Aphasia Examination
Reference unavailable
Communicative Abilities of Daily Living
CADL
Holland 1980; Holland 1998
Communicative Activity Log
CAL
Pulvermuller 2001
Communicative Effectiveness Index
CETI
Lomas 1989
Communicative Readiness and Use Scale and Psychological Wellbeing Index
Lyon 1997
Conversational Rating Scale
CRS
Wertz 1981
FCP
Sarno 1969

165
(Continued)
Functional-Expression scale
FE Scale
Prins 1980
General Health Questionnaire
GHQ
Goldberg 1972
Leal 1993 Aphasia Quotient
AQ
Castro-Caldas 1979
Minnesota Test for Differential Diagnosis MTDDA

of Aphasia
Schuell 1965
Multiple Adjective Affect CheckList
MAACL
Zuckerman 1965
Object Naming Test
ONT
Oldfield 1965
Philadelphia Comprehension Battery
PCB
Saffran 1988
Picture Description with Structured Mod- PDSM

eling
Fink 1994
Porch Index of Communicative Abilities
Porch 1967; Porch 1971; Porch 1981
PICA
Psycholinguistic Assessments of Language PALPA

Processing in Aphasia
Kay 1992; Bastiaanse 1995
Reading Comprehension Battery for Apha- RCBA

sia
LaPointe 1979
Semantic Association Test
Visch-Brink 1996
SAT
Token Test (shortened and standard ver- TT

sions)
DeRenzi 1962; Spreen 1969; Lincoln 1979
Western Aphasia Battery
Kertesz 1982
WAB
Western Aphasia Battery Aphasia Quotient WABAQ
Kertesz 1982
Word Fluency
Borkowski 1967

166
WHATS NEW
Last assessed as up-to-date: 8 November 2009.
Date
Event
Description
18 May 2010
Amended
Contact details updated.
HISTORY
Protocol first published: Issue 4, 1997
Review first published: Issue 4, 1999
Date
Event
Description
15 December 2008
New search has been performed
This is a major revision of the original review, which

was first published in 1999, and involves the use of
a new search strategy, amended objectives and refined
inclusion criteria for studies, types of interventions
and outcome measures of interest. Full details of the
amendments are listed in the Background section of
the review.
We have included 20 new trials, bringing the total
number of included studies to 30, involving 1840 participants
12 December 2008
New citation required but conclusions have not This update has been completed by a different team of
changed
authors
24 July 2008
Amended
Converted to new review format.
CONTRIBUTIONS OF AUTHORS
HK conducted the search, screened and retrieved references for inclusion or exclusion, contacted relevant authors and academic
institutions, obtained translations for non-English publications, obtained unpublished data, extracted the data from included trials,
evaluated methodological quality, entered data into RevMan, conducted data analysis, interpreted the data and co-wrote the review.
MB designed the review, retrieved references, screened references for inclusion and exclusion criteria and contributed to discussions
relating to these decisions, contacted relevant authors, obtained translations for non-English publications, obtained unpublished data,
extracted data from included trials, evaluated methodological quality, entered and analysed the data, interpreted the data and co-wrote
the review.
PE co-authored the original review and commented on the updated review.

167
DECLARATIONS OF INTEREST
Helen Kelly is a speech and language therapist.
Marian Brady is a speech and language therapist, member of the Royal College of Speech and Language Therapists, and is registered
with the Health Professions Council, UK.
Pam Enderby has been involved in two studies included in this review. She did not contribute to the assessment or interpretation of
either of these studies.
SOURCES OF SUPPORT
Internal sources
Nursing, Midwifery and Allied Health Professions Research Unit, UK.
Queen Margaret University, Edinburgh, UK.
External sources
Chief Scientist Office Scotland, UK.
INDEX TERMS
Medical Subject Headings (MeSH)
Language Therapy; Speech Therapy; Aphasia [ etiology; therapy]; Randomized Controlled Trials as Topic; Stroke [ complications]
MeSH check words

Humans

168

Speech and Language Therapy For Aphasia Following Stroke 2010

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Title

Speech and language therapy for aphasia following stroke

Kelly, Helen; Brady, Marian C.; Enderby, Pam

Kelly H, Brady MC, Enderby P. Speech and language therapy for

Copyright 2010 The Cochrane Collaboration.

Speech and language therapy for aphasia following stroke

Speech and language therapy for aphasia following stroke (Review)

Speech and language therapy for aphasia following stroke (Review)

Speech and language therapy for aphasia following stroke

PLAIN LANGUAGE SUMMARY

Speech and language therapy for aphasia following stroke (Review)

Amendments to the original review

Types of outcome measures

Data extraction tool

We could not obtain the original data extraction tool, therefore

Search methods for identification of studies

Re-running the original search strategy for the MEDLINE and

The original review listed studies other than identified randomised

Speech and language therapy for aphasia following stroke (Review)

1. SLT is more effective than no SLT;

Criteria for considering studies for this review

New information added to the review

Speech and language therapy (SLT)

Speech and language therapy for aphasia following stroke (Review)

extended this definition to include therapists belonging to a body

Search methods for identification of studies

Types of outcome measures

See the Specialized register section in the Cochrane Stroke Group

We searched the Cochrane Stroke Group Trials Register, which was

Speech and language therapy for aphasia following stroke (Review)

Communication) from 1969 to December 2005. Since 2006 this

Data collection and analysis

Data extraction and management

tempted to contact investigators for any missing data (or data in

Assessment of risk of bias in included studies

Measures of treatment effect

Speech and language therapy for aphasia following stroke (Review)

Subgroup analysis and investigation of heterogeneity

Speech and language therapy for aphasia following stroke (Review)

of included studies. As we used paired subcomparisons within this

We included 14 subcomparisons in this section (Doesborgh

interventions that included one active treatment or placebo either

Speech and language therapy for aphasia following stroke (Review)

1997); 19 years (Katz 1997i); or up to 22 years (Katz 1997ii)

2. SLT versus social support and stimulation

We included six subcomparisons in this section (David 1982;

up to four weeks (Shewan 1984ii; Shewan 1984iii); up to three

3. SLT A versus SLT B

We included 21 subcomparisons (732 randomised participants)

Speech and language therapy for aphasia following stroke (Review)

(Prins 1989; van Steenbrugge 1981), three hours (Di Carlo

Risk of bias in included studies

Wertz 1986iii) and three randomised more than 150 participants

Speech and language therapy for aphasia following stroke (Review)

isons (Jufeng 2005i; Jufeng 2005ii; Jufeng 2005iii; Lincoln 1984b;

1982 described blinding of outcome assessors but they also report

Speech and language therapy for aphasia following stroke (Review)

Other potential sources of bias

Comparison 1: SLT versus no SLT

Speech and language therapy for aphasia following stroke (Review)

Eight of the 14 subcomparisons (Doesborgh 2004b; Katz 1997i;

Communication Activities of Daily Living (CADL)

Four subcomparisons used the CADL to compare the functional